Search

We evaluated post-heart transplant (HTx) outcomes after use of higher-risk donor hearts for candidates supported with pre-HTx mechanical circulatory support (MCS). In this retrospective analysis of the national United Network for Organ Sharing registry, a total of 9,915 adult candidates on MCS underwent HTx from January 1, 2010 to March 31, 2019. Multi-organ, re-transplant, and congenital heart disease patients were excluded. Higher-risk donor organs met at least one of the following criteria: left ventricular ejection fraction <50%, donor to recipient predicted heart mass ratio <0.86, donor age >55 years, or ischemic time >4 hours. Primary outcome was 1 year post-transplant survival. Among HTx recipients, 3688 (37.2%) received higher-risk donor hearts. Candidates supported with pre-HTx extracorporeal membrane oxygenation or biventricular assist device (n = 374, 3.8%) who received higher-risk donor hearts had comparable 1 year survival (HR: 1.14, 95% CI: [0.67-1.93], p = 0.64) to recipients of standard-risk donor hearts, when adjusted for recipient age and sex. In candidates supported with intra-aortic balloon pump (n = 1391, 14.6%), transplantation of higher-risk donor hearts did not adversely affect 1 year survival (HR: 0.80, 95% CI: [0.52-1.22], p = 0.30). Patients on durable left ventricular assist devices (LVAD) who received higher-risk donor hearts had comparable 1 year survival to continued LVAD support on the waitlist, but mortality was increased compared to those who received standard-risk donor hearts (HR: 1.37, 95% CI: [1.11-1.70], p = 0.004). Patients requiring pre-HTx temporary MCS who received higher-risk donor hearts had comparable 1 year post-transplant survival to those who received standard-risk donor hearts. Stable patients on durable LVADs may benefit from waiting for standard-risk donor hearts. [ABSTRACT FROM AUTHOR]

Background: Cardiac allograft vasculopathy (CAV) is the leading cause of late graft loss. While there are numerous post‐transplant factors which may increase the risk of the development of CAV, there is a paucity of data on the impact of donor‐derived atherosclerosis (DA), early discontinuation of prednisone, and early initiation of proliferation signal inhibitors (PSI) as assessed by intravascular ultrasound (IVUS). Methods: Retrospective single‐center study of all adult transplant patients (2008‐2017) with serial IVUS at baseline and annually for 5 years. DA was defined as a baseline maximal intimal thickness (MIT) ≥0.5 mm, and CAV development was defined as MIT ≥1 mm or an increase in MIT ≥0.5 mm at year 1 compared with baseline or an increase in 0.3 mm annually thereafter. Clinical risk factors for CAV were identified using multivariable hazard regression. Separate multistate models were applied to assess the association of prednisone discontinuation and PSI initiation and CAV. Results: Of 282 patients screened, 186 patients had a 1‐year angiogram. The mean age of those included in the cohort was 51 ± 11 years, 70% were male, 58% were Caucasian, and 27% were supported by a left ventricular assist device. Donor atherosclerosis was present in 40%. The cumulative incidence of CAV at 5 years is 41% in DA‐ vs. 59% in DA + (p =.012). Donor age was a strong predictor of DA (p =.016). Significant risk factors for CAV included male sex (HR = 4.141, p =.001), non‐Caucasian race (HR = 1.98, p =.011), BMI < 18 kg/m2 (HR = 4.596, p =.042), longer ischemic time (HR = 1.374, p =.028), older donor age (HR = 1.158, p =.009), and rejection with hemodynamic compromise within the first year (HR = 2.858, p =.043). Prednisone discontinuation within 1 year was associated with a lower risk of CAV (HR 0.58 p =.047). Initiation of proliferation signal inhibitors (PSI) within 2 years resulted in fewer cases of CAV (HR 0.397 p <.001). Conclusion: In patients with an angiogram at 1 year, those with DA were significantly more likely to develop CAV. Lower incidence of CAV by IVUS was seen in patients who discontinued prednisone in the first year or had initiation of a PSI within two years of transplantation. Knowledge of early IVUS may allow a more tailored approach to patient management. [ABSTRACT FROM AUTHOR]

We commend the authors on the landmark RESTAGE-HF study (Remission from Stage D Heart Failure).[1] Birks et al have established important foundational work on the novel concept of left ventricular assistance device (LVAD)-enabled pharmacotherapy intensification for myocardial recovery. A more comprehensive baseline analysis of the enrolled patients would help the reader compare the results with their own patient population, allowing a targeted approach toward LVAD explantation. [Extracted from the article]

Background: Despite significant advances in durable mechanical support survival, infectious complications remain the most common adverse event after ventricular assist device (VAD) implantation and the leading cause of early death after transplantation. In this study, we aim to describe our local infectious epidemiology and review short‐term survival and infectious incidence rates in the post‐transplantation period and assess risk factors for infectious episodes after transplantation. Methods: Retrospective single‐center study of all consecutive adult heart transplant patients from 2008 to 2017. Survival data were estimated and summarized using the Kaplan‐Meier method. We quantified and evaluated the difference in the incidence rate between patients with and without infection using a Fine‐Gray model. The outcome of interest is the time to first infection diagnosis with post‐transplant death as the competing event. Results: Among 278 heart transplant patients, 74 (26.5%) underwent LVAD implantation. Twenty‐one patients (28.3%) developed an infection while supported by an LVAD. When compared to patients supported by an LVAD without a preceding infection, BMI was significantly greater (31.2 vs 27.8 kg/m2, P = .03). Median follow‐up post‐transplantation was 3.01 years. Significant risk factors for the competing risk regression for infection after heart transplantation include LVAD infection (HR 1.94, [95% CI] 1.11‐3.39, P = .020) and recipient COPD (HR 2.14, [95% CI] 1.39‐3.32, P = .001) when adjusted for recipient age, gender, hypertension, diabetes mellitus, and body mass index. Conclusions: Patients with LVAD‐related infection had a significantly increased risk of infectious complications after heart transplantation. Further research on the avoidance of induction agents and reduced maintenance immunosuppression in this patient population is warranted. [ABSTRACT FROM AUTHOR]