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Background: Extracorporeal membrane oxygenation (ECMO) has gained traction as a bridge to heart transplantation (HT) but remains associated with increased waitlist mortality. This study explores whether this risk is modified by underlying heart failure (HF) etiology., Methods: Using the Organ Procurement and Transplantation Network registry, we conducted a retrospective review of first-time adult HT candidates from 2018 through 2022. Patients were categorized as "ECMO", if ECMO was utilized during the waitlisting period, or "No ECMO" otherwise. Patients were then stratified according to the following HF etiology: ischemic cardiomyopathy (CMP), dilated nonischemic CMP, restrictive CMP, hypertrophic CMP, and congenital heart disease (CHD). After baseline comparisons, waitlist mortality was characterized for ECMO and HF etiology using the Fine-Gray regression., Results: A total of 16 143 patients were identified of whom 7.0% (n = 1063) were bridged with ECMO. Compared to No ECMO patients, ECMO patients had shorter waitlist durations (46.3 vs. 185.0 days, p < 0.01) and were more likely to undergo transplantation (75.3% vs. 70.3%, p < 0.01). Outcomes analysis revealed that ECMO was associated with increased mortality risk (subdistribution hazard ratio [SHR]: 3.42, p < 0.01), a risk that persisted in all subgroups and was notably high in CHD (SHR: 4.83, p < 0.01) and hypertrophic CMP (SHR: 9.78, p < 0.01). HF etiology comparison within ECMO patients revealed increased mortality risk with CHD (SHR: 3.22, p < 0.01). Within No ECMO patients, hypertrophic CMP patients had lower mortality risk (SHR: 0.64, p = 0.03)., Conclusions: The increased waitlist mortality risk with ECMO persisted after stratification by HF etiology. These findings can help decision-making surrounding candidacy for cannulation and prognostic evaluation., (© 2024 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Donation after circulatory death (DCD) has reemerged as a method of expanding the donor heart pool. Given the high waitlist mortality of multiorgan heart candidates, we evaluated waitlist outcomes associated with willingness to consider DCD offers and post-transplant outcomes following DCD transplant for these candidates., Methods: We identified adult multiorgan heart candidates and recipients between January 1, 2020 and March 31, 2023 nationally. Among candidates that met inclusion criteria, we compared the cumulative incidence of transplant, with waitlist death/deterioration as a competing risk, by willingness to consider DCD offers. Among recipients of DCD versus brain death (DBD) transplants, we compared perioperative outcomes and post-transplant survival., Results: Of 1,802 heart-kidney, 266 heart-liver, and 440 heart-lung candidates, 15.8%, 12.4%, and 31.1%, respectively, were willing to consider DCD offers. On adjusted analysis, willingness to consider DCD offers was associated with higher likelihood of transplant for all multiorgan heart candidates and decreased likelihood of waitlist deterioration for heart-lung candidates. Of 1,100 heart-kidney, 173 heart-liver, and 159 heart-lung recipients, 5.4%, 2.3%, and 2.5%, respectively, received DCD organs. Recipients of DCD and DBD heart-kidney transplants had a similar likelihood of perioperative outcomes and 1-year survival. All other DCD multiorgan heart recipients have survived to the last follow-up., Conclusions: Multiorgan heart candidates who were willing to consider DCD offers had favorable waitlist outcomes, and heart-kidney recipients of DCD transplants had similar post-transplant outcomes to recipients of DBD transplants. We recommend the use of DCD organs to increase the donor pool for these high-risk candidates., (Copyright © 2024 International Society for the Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Introduction: Higher donor sequence numbers (DSNs) might spark provider concern about poor donor quality. We evaluated characteristics of high-DSN offers used for transplant and compared outcomes of high- and low-DSN transplants., Materials and Methods: Adult isolated heart transplants between January 1, 2015, and December 31, 2022, were identified from the organ procurement and transplantation network database and stratified into high (≥42) and low (<42) DSN. Postoperative outcomes, including predischarge complications, hospital length of stay, and survival at 1 and 3 y, were evaluated using multivariable regressions., Results: A total of 21,217 recipients met the inclusion criteria, with 2131 (10.0%) classified as high-DSN. Donor factors associated with greater odds of high-DSN at acceptance included older age, higher creatinine, diabetes, hypertension, and lower left ventricular ejection fraction. Recipients accepting high-DSN offers were older and more likely to be female, of blood type O, and have lower status at transplant. High- and low-DSN transplants had similar likelihood of stroke (3.2% versus 3.5%; P = 0.97), dialysis (12.3% versus 13.5%; P = 0.12), pacemaker implant (2.3% versus 2.1%; P = 0.64), had similar lengths of stay (16 [12-24] versus 16 [12-25] days, P = 0.38), and survival at 1 (91.6% versus 91.6%; aHR 0.85 [0.72-1.02], P = 0.08) and 3 y (84.2% versus 85.1%; aHR 0.91 [0.79-1.05], P = 0.21) post-transplant., Conclusions: High-DSN (≥42) was not an independent risk factor for post-transplant mortality and should not be the sole deterrent to acceptance. Accepting high-DSN organs may increase access to transplantation for lower-status candidates., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: While stroke is a well-recognized complication of isolated heart transplantation, stroke in patients undergoing simultaneous heart-liver (HLT) and heart-kidney transplantation (HKT) has not been explored. This study assessed postoperative stroke incidence, risk factors, and outcomes in HLT and HKT compared with isolated heart transplant., Methods: The United Network for Organ Sharing database was queried for adult patients undergoing HLT, HKT, and isolated heart transplants between 1994 and 2022. Patients were stratified by presence of in-hospital stroke after transplant. Post-transplant survival at 1-year was assessed using Kaplan-Meier analysis and log-rank tests. Separate multivariable logistic regression models were constructed to identify risk factors for stroke after HKT and HLT., Results: Of 2326 HKT recipients, 85 experienced stroke, and of 442 HLT recipients, 19 experienced stroke. Stroke was more common after HKT and HLT than after an isolated heart transplant (3.7% vs. 4.3% vs. 2.9%, p = 0.01). One-year post-transplant survival was lower in those with stroke among both HKT recipients (64.5% vs. 88.7%, p(log-rank) < 0.001) and HLT recipients (43.8% vs. 87.4%, p(log-rank) < 0.001. Pre-transplant pVAD, prior stroke, postoperative dialysis, diabetes, prior cardiac surgery, and heart cold ischemic time were independent risk factors for stroke after HKT, after adjusting for age, sex, and need for blood transfusion on the waitlist. For HLT, postoperative dialysis was a significant risk factor., Conclusions: Stroke is more common after HKT and HLT than after isolated heart transplant, and results in poor survival. Independent risk factors for stroke include pre-transplant percutaneous VAD (HKT) and postoperative dialysis (HKT and HLT)., (© 2024 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Patients with severe heart disease may have coexisting liver disease from various causes. The incidence of combined heart-liver transplant (CHLT) is increasing as more patients with congenital heart disease survive to adulthood and develop advanced heart failure with associated liver disease from chronic right-sided heart or Fontan failure. However, the criteria for CHLT have not been established. To address this unmet need, a virtual consensus conference was organized on June 10, 2022, endorsed by the American Society of Transplantation. The conference represented a collaborative effort by experts in cardiothoracic and liver transplantation from across the United States to assess interdisciplinary criteria for liver transplantation in the CHLT candidate, surgical considerations of CHLT, current allocation system that generally results in the liver following the heart for CHLT, and optimal post-CHLT management. The conference served as a forum to unify criteria between the different specialties and to forge a pathway for patients who may need dual organ transplantation. Due to the continuing shortage of available donor organs, ethical issues related to multiorgan transplantation were also debated. The findings and consensus statements are presented., (Copyright © 2023 American Society of Transplantation & American Society of Transplant Surgeons. Published by Elsevier Inc. All rights reserved.)

Stroke is a well-characterized complication of isolated heart and lung transplantation, but has not been described in combined heart-lung transplantation (HLTx). We retrospectively reviewed national U.S. data to describe the incidence, risk factors, and impact of postoperative stroke in HLTx recipients. Of 871 heart-lung recipients between 1994-2022, 35 (4.0%) experienced stroke, and the incidence increased over time, trending toward significance (p-trend = .07). After adjustment, extracorporeal membrane oxygenation (ECMO) (Adjusted odds ratio [aOR] = 2.63, 95%CI = [1.13-6.11]) and pre-transplant implantable defibrillator (aOR = 2.86, 95%CI = [1.20-6.81]) were independent risk factors for stroke. Postoperative stroke is common and is increasing in an era where organ allocation is driven by mechanical circulatory support (MCS) bridging., (© 2023 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

With the demand for heart transplantation continuing to outpace the available donor organs, previously underutilized donors are now being reconsidered. We sought to describe the emerging techniques and outcomes of expanded criteria heart transplantation. A comprehensive review of the recent literature concerning expanded donor selection in heart transplantation was performed using the PubMed MEDLINE database. To characterize trends in transplant practice, the United Network for Organ Sharing (UNOS/OPTN) registry was queried for all adult isolated heart transplants since 2010, and data regarding transplant parameters was collected. Donation after cardiac death (DCD), DCD with normothermic regional perfusion, increased ischemic time, hepatitis C positive donor organs, HIV-positive donor organs, and extended criteria donors were identified as promising avenues currently being explored to expand the number of donor organs. The utilization of various expanded criteria for heart transplantation was summarized since 2010 and showed an increasing use of these donor organs, contributing to the overall increasing frequency of heart transplantation. Utilization of expanded criteria for donor selection in heart transplantation has the potential to increase the supply of donor organs with comparable outcomes in selected recipients.

Introduction: We investigated how the 2018 Organ Procurement and Transplantation Network heart allocation policy change was associated with changes in characteristics and outcomes of candidates receiving multiple temporary mechanical circulatory support (mtMCS) devices., Materials and Methods: We included adult heart transplant candidates listed October 2014-January 2018 and October 2018-January 2022 in the United Network of Organ Sharing dataset. Prepolicy and postpolicy mtMCS recipients were compared at listing, transplant, 90-days, and 1-year post-transplant. Time between first and second devices and time between first device and transplant were modeled via multivariable linear regression. Transplantation likelihood was modeled using competing risks analysis., Results: Postpolicy, a higher proportion of transplant candidates received mtMCS (4% versus 1%, P < 0.001), and received their second device an adjusted 49 d sooner versus prepolicy (P = 0.001). Time to transplant was also an adjusted 35 d shorter postpolicy, with an 80% increased transplantation likelihood versus prepolicy (95% confidence interval: 1.6-1.9, P < 0.001). Postpolicy patients experienced reduced waitlist mortality (8% versus 14%, P = 0.04) with marked improvements in 90-day (93% versus 85%, P < 0.001) and 1-year (88% versus 70%, P = 0.01) post-transplant survival., Conclusions: Postpolicy mtMCS recipients are more likely to progress to transplantation sooner on the waitlist and their shorter waitlist course together with earlier change to a secondary device was associated with improved post-transplant survival versus prepolicy., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Available literature indicates the possible detrimental effect of sex mismatching on mortality in patients undergoing heart transplantation. Our objective was to examine the role of sex and heart mass (predicted heart mass [PHM]) mismatch on mortality and graft rejection in patients undergoing heart transplantation in the US., Methods: Data on adult patients who underwent heart transplantation between January 2015 and October 2021 were queried from the United Network of Organ Sharing (UNOS) registry. The main outcomes were all-cause mortality, 1-year all-cause mortality and treated acute rejection., Results: A total of 19 805 adult patients underwent heart transplant during the study period. 92.2% of the patients in the female graft to male group had a PHM mismatch <25%, while only 38.5% had such a mismatch in the male graft to female group. In male to male and female to female groups, 79% and 76% of the patients had a PHM mismatch <25% (p = .122). Proportion of PHM mismatch was similar throughout the study period. Unadjusted analysis showed that male recipients of female grafts had increased risk for all-cause mortality (hazard ratio [HR]: 1.13; 95% confidence intervals [CI]: 1.02, 1.27; p = .026) and 1-year mortality (HR: 1.26; 95% CI: 1.09, 1.45; p = .002) compared to male recipients of male grafts. Graft failure incidence was also higher (HR: 1.12; 95% CI: 1.01, 1.25; p = .041). However, all these associations were non- significant after risk factor adjustment., Conclusions: Sex mismatching is associated with post-transplant mortality with transplantation of female donor grafts to male recipients demonstrating worse outcomes, although this association disappears after risk factor adjustment. Further research is required to elucidate the need for potential changes in clinical practice., (© 2022 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Ventricular assist devices (LVADs) are commonly used in end-stage heart failure for mechanical circulatory support as a bridge to heart transplantation. However, LVADs' long-term effects on posttransplant survival are unknown. We sought to compare long-term mortality after transplantation for patients with and without LVADs. Using the Organ Procurement and Transplantation Network database, we investigated LVADs' impact on long-term (3 month, 1 year, 2 years, 5 years, and 8 years) posttransplant mortality risk for all heart transplant recipients between 2010 and 2019. Time-to-event regression analysis quantified mortality risk by LVAD status in both unconditional and conditional survival analyses. Of 20,113 transplant recipients, 8,999 (45%) had a LVAD while on the waitlist. Among those who died after transplantation, patients with LVADs on average died sooner (1.8 years) than patients without LVADs (3.0 years; p < 0.01). On multivariable analysis, patients with LVADs had a 44% higher mortality risk within the first 3 months posttransplant (HR = 1.44, p = 0.03). There was no significant difference in mortality risk between patients who did and did not have pretransplant LVADs after 1, 2, and 5 years of posttransplant conditional survival. While LVAD patients have a survival disadvantage in the first year posttransplant, conditional survival analysis demonstrated no difference in mortality risk between patients with and without LVADs beyond 1 year of follow up. Of the patients who died posttransplant, patients with LVADs on average died sooner than patients without LVADs., Competing Interests: The authors have no conflicts of interest or sources of funding to disclose., (Copyright © ASAIO 2022.)

Aims: End-stage heart failure necessitating evaluation for heart transplantation is increasingly recognized in arrhythmogenic right ventricular cardiomyopathy (ARVC). These patients present unique challenges in pre-transplant and peri-transplant management given their predominantly right ventricular (RV) failure and propensity for ventricular arrhythmias. We sought to utilize a tertiary ARVC referral and heart transplant centre experience to describe management of a series of patients with ARVC undergoing heart transplantation at our centre., Methods and Results: We queried the Johns Hopkins ARVC Registry for all patients who underwent heart transplantation and further studied the subset undergoing transplantation at the Johns Hopkins Hospital. Patient demographics, clinical characteristics, and pre-transplant clinical course were obtained from the registry and electronic medical records. Of the 532 patients in the ARVC Registry, 63 (12%) underwent heart transplantation. Nine (six male) of these patients both had known ARVC prior to transplant and were transplanted at Johns Hopkins Hospital between 2006 and 2020 at a mean age of 42 ± 14 years old. Pathogenic ARVC genetic variants were identified in six (67%) patients, all of whom had variants in the plakophilin-2 (PKP2) gene. RV failure was universal with median right atrial to pulmonary capillary wedge pressure (RA/PCWP) ratio of 1.4 [interquartile range (IQR) 1.2-1.5] and median right ventricular stroke work index (RVSWI) of 0 g·m/m 2 /beat (IQR 0-0.3). Six had a history of catheter ablation for ventricular arrhythmia with five of the six having at least three ablations. Transplant evaluation was initiated an average of 344 ± 407 days after first developing heart failure symptoms. The most common bridge to transplant support included inotropes (n = 3) and extracorporeal membrane oxygenation (ECMO) (n = 2). Contraindication to inotropes or mechanical support was common due to ventricular arrhythmia and RV predominant cardiomyopathy., Conclusions: Heart transplantation is a curative treatment for ARVC, but due to frequent ventricular arrhythmias and RV predominant pathology, patients require unique considerations in regard to timing of evaluation, haemodynamic support options, and wait listing qualification., (© 2021 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Aims: Heart failure is an increasingly recognized later stage manifestation of arrhythmogenic right ventricular cardiomyopathy (ARVC) that can require heart transplantation (HT) to appropriately treat. We aimed to study contemporary ARVC HT outcomes in a national registry., Methods and Results: The United Network for Organ Sharing registry was queried for HT recipients from 1/1994 through 2/2020. ARVC patients were compared with non-ARVC dilated, restrictive, and hypertrophic cardiomyopathy HT patients (HT for ischaemic and valvular disease was excluded from analysis). Post-HT survival was assessed using Kaplan-Meier estimates. A total of 189 of 252 (75%) waitlisted ARVC patients (median age 48 years, 65% male) underwent HT, representing 0.3% of the total 65 559 HT during the study time period. Annual frequency of HT for ARVC increased significantly over time. ARVC patients had less diabetes (5% vs. 17%, P < 0.001), less cigarette use (15% vs. 23%, P < 0.001), lower pulmonary artery and pulmonary capillary wedge pressures, and lower cardiac output than the 33 659 non-ARVC patients (P < 0.001). Ventricular assist device use was significantly lower in ARVC patients (8% vs. 32%, P < 0.001); 1 and 5 year post-HT survival was 97% and 93% for ARVC vs. 95% and 82% for non-ARVC HT recipients (P < 0.001). On adjusted multivariable Cox regression, ARVC had decreased risk of post-HT death compared with non-ARVC aetiologies (hazard ratio 0.48, 95% confidence interval 0.28-0.82, P = 0.008). Patients with ARVC also had lower risk of death or graft failure than non-ARVC patients (hazard ratio 0.51, 95% confidence interval 0.32-0.81, P = 0.004)., Conclusions: In the largest series of HT in ARVC, we found that HT is increasingly performed in ARVC, with higher survival compared with other cardiomyopathy aetiologies. The right ventricular predominant pathophysiology may require unique considerations for heart failure management, including HT., (© 2021 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Background: Cardiac sarcoidosis is an increasingly common indication for a heart transplant, but there is a paucity of knowledge with regard to long-term outcomes following transplant., Methods: We utilized the Organ Procurement and Transplantation Network database to retrospectively analyze adult patients undergoing first-time, single-organ heart transplant between January 1999 and March 2020., Results: Of the 41,447 patients that underwent heart transplant during the study period, 289 (0.7%) were transplanted for a primary diagnosis of restrictive cardiomyopathy due to cardiac sarcoidosis (RCM-Sarcoidosis). RCM-Sarcoidosis was associated with 33% reduced risk of mortality over 10 years compared to non-RCM indications in a multivariable Cox proportional hazards model (p = .03). Ten-year survival functions were improved among RCM-Sarcoidosis compared to this reference group (73.4% [64.2%-80.6%] vs. 59.5% [58.8%-60.1%], p = .002). Among patients transplanted after 1999 who had at least 10 years of follow-up (n = 19,489), median survival of RCM-Sarcoidosis patients was 11.9 [8.3-14.6] years while that of non-RCM patients was 9.9 [4.0-13.1] years. RCM-Sarcoidosis was not associated with an increased risk of secondary outcomes such as graft failure, rejection, or infection. The incidence of retransplant was comparable between RCM-Sarcoidosis and non-RCM patients (1.38% vs. 1.50%, p = .93)., Conclusions: These data suggest that long-term outcomes following transplant for cardiac sarcoidosis are favorable compared to heart transplant for other indications., (© 2021 The Authors. Journal of Cardiac Surgery Published by Wiley Periodicals LLC.)

Background: The incidence of systemic amyloidosis is rising, and there is a concomitant rise in heart transplant for an indication of cardiac amyloidosis., Methods: We utilized the Organ Procurement and Transplantation Network (OPTN) database to retrospectively assess survival and outcomes in adult patients undergoing heart transplant for cardiac amyloidosis from 1999 to 2019. We also compared survival among four distinct time periods: 1999-2001, 2002-2008, 2008-2015, 2016-2019., Results: Of 41,103 patients, 425 (1.03%) were transplanted for an indication of restrictive cardiomyopathy due to cardiac amyloidosis (RCM-Amyloidosis). The percent of all transplants occurring for RCM-Amyloidosis increased from 0.25% in the 1999-2001 era to 1.74% in the 2015-2019 era (p < .001). Across eras, Kaplan-Meier survival functions were comparable between RCM-Amyloidosis and non-RCM patients at 1 year (88% vs. 89%, p = .56) and at 5 years (72% vs. 77%, p = .092), but worse for RCM-Amyloidosis patients at 10 years (44% vs. 59%, p = .002). With adjustment for other clinical variables in multivariable Cox regression model, RCM-Amyloidosis was not associated with increased risk of death at 1 year (hazard ratio [HR] = 1.11, p = .56) or at 5 years (HR = 1.20, p = .18), but it was associated with increased risk of death at 10 years (HR = 1.35, p = .01). Cardiac amyloidosis was not associated with any morbidity outcomes following transplant, including graft failure, acute rejection, or hospitalization for infection or rejection., Conclusions: Our data suggest a trend of improving survival among RCM-Amyloidosis patients compared with non-RCM patients across transplant eras, with current similarities in 1- and 5-year survival but a persistent, increased risk of mortality at 10 years., (© 2021 The Authors. Journal of Cardiac Surgery published by Wiley Periodicals LLC.)

Background: With the implementation of the new heart allocation system, heart transplantation teams are prompted to reevaluate management of patients requiring mechanical circulatory support. The purpose of our study is to compare the outcomes of patients supported with extracorporeal membrane oxygenation (ECMO) before transplantation., Methods: The United Network for Organ Sharing database was queried for all adult patients (aged 18 years or more) who required support with ECMO before heart transplantation from 2001 to 2018. Patients were stratified into patients who did not require ECMO before transplantation, who were weaned off ECMO before transplantation, who were bridged immediately to transplantation from ECMO, and who were bridged to a left ventricular assist device (LVAD) before transplantation. Demographics and outcomes including 1-year survival, postoperative stroke, postoperative renal failure requiring dialysis, episodes of rejection, and graft failure were compared., Results: Overall, 29,370 patients did not require ECMO before transplantation, 101 patients were weaned off ECMO before transplantation, 118 were bridged from ECMO directly to transplantation, and 55 patients were successfully bridged from ECMO to LVAD before transplantation. Kaplan-Meier survival estimates found a statistically significant decrease in 1-year survival for patients who were bridged from ECMO to transplantation compared with patients who were bridged to LVAD before subsequent transplantation (P < .001)., Conclusions: Our study suggests bridging ECMO patients to an LVAD before transplantation will result in improved 1-year survival compared with patients bridged to immediate transplantation. With the new heart allocation system, continued evaluation of outcomes is required to inform management strategies., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: Validated scoring tools, such as the Nutritional Risk Index (NRI), can aid clinicians in quantifying the degree of malnourishment in patients prior to an operation. We evaluated the association between NRI and outcomes after heart transplantation., Methods: The United Network for Organ Sharing (UNOS) database was used to identify adult patients (age > 18) undergoing heart transplantation between 1987 and 2016. NRI was calculated and categorized into previously established groupings representing severity of malnutrition. Multivariate Cox proportional hazards modeling were used to assess the primary outcome of all-cause mortality., Results: A total of 25,236 patients were included in the analysis. Most patients (75.4%) were male. Malnourishment was absent (NRI ≥ 100) in 11,022 (44%) patients, while 2,898 (12%) were mildly malnourished (97.5 ≤ NRI < 100), 8,685 (34%) were moderately malnourished (83.5 ≤ NRI < 97.5), and 2,631 (10%) were severely malnourished (NRI < 83.5). Moderate-to-severe malnutrition was associated with increased mortality (HR = 1.18, p < .001, 95%CI: 1.13-1.24), and post-transplant renal failure requiring dialysis (OR: 1.13, p < .001, 95%CI: 1.03-1.23)., Conclusion: Malnourishment determined by NRI is independently associated with mortality and post-transplant dialysis after heart transplant. This is the largest study of NRI in heart transplant recipients., (© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Transplant patients are known to have increased risk of developing de novo malignancies (DNMs). As post-transplant survival increases, DNM represents an obstacle to further improving survival. We sought to examine the incidence, types, and risk factors for post-transplant DNM., Methods: We studied adult heart transplant recipients from the Organ Procurement and Transplantation Network database (1987-2018). Kaplan-Meier survival analysis was performed to determine annual probabilities of developing DNM, excluding squamous and basal cell carcinoma. Rates were compared to the general population in the Surveillance, Epidemiology, and End Results database. Cox proportional hazards regression was performed to calculate hazard ratios for risk factors of DNM development, all-cause, and cancer-specific mortality., Results: Over median follow-up of 6.9 years, 18% of the 49,361 patients developed DNM, which correlated with an incidence rate 3.8 times that of the general population. The most common malignancies were lung, post-transplant lymphoproliferative disorder, and prostate. Risk was most increased for female genital, tongue/throat, and renal cancers. Male gender, older age, smoking history, and impaired renal function were risk factors for developing DNM, whereas the use of MMF for immunosuppression was protective. Cigarette use, increasing age, the use of ATG for induction and calcineurin inhibitors for maintenance were risk factors for cancer-specific mortality. The development of a DNM increased the risk of death by 40% (p < .001)., Conclusions: Heart transplant patients are at increased risk of malignancy, particularly rare cancers, which significantly increases their risk of death. Strict cancer surveillance and attention to immunosuppression are critical for prolonging post-transplant survival., (© 2021 Wiley Periodicals LLC.)

Background: Heart transplantation is the mainstay of treatment for patients in end-stage heart failure. This study sought to contrast survival after transplantation with that of the general population to quantify standardized mortality rates using a nested case-control study design., Methods: Control subjects were noninstitutionalized inhabitants of the United States identified through the National Longitudinal Mortality study. Case subjects were adults who underwent heart transplantation between 1990 and 2007 and identified through the Organ Procurement and Transplantation Network. Propensity-matching (5:1, nearest neighbor, caliper = 0.1) was utilized to identify suitable control subjects based on age, sex, race, and state of permanent residency. The primary study endpoint was 10-year survival., Results: In all, 31,883 heart transplant recipients were matched to 159,415 noninstitutionalized residents of the United States. The 10-year survival of heart transplant recipients was 53%. The population expected mortality rate was 15.9 deaths per 100 person-years with an observed rate of 45.1 deaths per 100 person-years (standardized mortality rate [SMR] 2.84; 95% confidence interval, 2.82 to 2.87). The broadest gaps between observed and expected survival were evident in female (SMR 3.63), black (SMR 3.67), and Hispanic (SMR 4.12) recipients. Standardized mortality ratios declined over time (1990 to 1995, 3.09; 1996 to 2000, 2.90; 2001 to 2007, 2.58). The long-term standardized survival of older recipients was closest to that expected for their age., Conclusions: Heart transplant recipients have considerable long-term survival and have a threefold higher standardized long-term mortality rate than that of the noninstitutionalized population. Long-term mortality rates have consistently declined over time and will likely continue to decrease., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The new heart transplant allocation criteria prioritize inpatients who require temporary mechanical circulatory support and give lower urgency to candidates on a durable left ventricular assist device (LVAD) who require a device exchange. This study explores whether the latter group should warrant higher priority to reduce wait-list mortality., Methods: This is a retrospective observational study of 13,113 adult heart transplant candidates in the Organ Procurement and Transplantation Network database who underwent LVAD implantation between 2007 and 2017. It evaluates the impact of LVAD exchange on the composite endpoint of death or removal from the wait list owing to worsening medical condition 1 y after device implantation., Results: There were 1085 pump exchanges in 954 patients (7% of candidates), of which 22% were women. The pump exchange rate was 5.92 events per 100 patient-years. One-year survival was lower for those who required a pump exchange (76.3% versus 88.5%, logrank P < 0.001). This was congruent with the risk-adjusted mortality 1-y after implantation (hazards ratio: 2.56, 95% confidence interval: 2.18-3.00, P < 0.001)., Conclusions: These findings indicate that among candidates awaiting heart transplantation with a durable LVAD, undergoing pump exchange doubles the risk of 1-y mortality. Giving priority to these candidates may reduce wait-list mortality., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Survival after heart transplantation is typically reported only in terms of overall survival. Conditional survival may provide prognostic information for patients after surviving a given period. This study sought to provide an analysis of conditional survival in heart transplantation., Methods: Data from 29,000 patients who underwent heart transplantation between 2002 and 2016 were analyzed from the Organ Procurement and Transplantation Network database, and 5-year conditional survival rates were calculated according to age, sex, race, renal function, and hepatic function at transplantation., Results: As time from transplantation increased from 0 to 5 years, the 5-year observed conditional survival changed from 74% to 82% for ages younger than 40 years, 79% to 82% for ages 40 to 49, 79% to 78% for ages 50 to 60, and 75% to 70% for ages older than 60 at transplantation. Conditional survival peaked at 1 and 2 years after transplantation for most subgroups. In recipients younger than 40 years, men had slightly higher conditional survival than women (absolute difference, 3%-4%). In recipients older than 60 years, women had slightly higher conditional survival (absolute difference, 1%-4%). Black recipients had lower survival than white and Hispanic recipients for nearly all time points. Recipients younger than 40 years with the worst renal (65% to 88%) and hepatic function (66% to 83%) at transplantation experienced the largest increase in conditional survival., Conclusions: The conditional survival of patients who undergo heart transplantation changes substantially over time. The largest increases in conditional survival are in young patients with impaired renal and hepatic function. Conditional survival can provide more accurate prognostic information for heart recipients who survive a given period after transplantation., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Ventricular assist devices (VADs) are commonly employed as a bridge to transplantation for heart failure. The full effects of VADs on transplantation rates are not fully understood. We sought to compare transplantation rates stratified by age and VAD status., Methods: Using the Organ Procurement and Transplantation Network (OPTN) database, we investigated the impact of age and VAD status on heart allocation rates among all transplant-eligible patients from January 2005 to September 2018. Patients were grouped based on the presence (+) or absence (-) of a VAD as well as age (<45, 45-65, and >65 years). Demographics were compared with a multivariate competing risk analysis that yielded risk-adjusted subdistribution hazard ratios (SHR)., Results: Among the 50 602 total waitlist candidates, 18 271 patients with a VAD had higher rates of diabetes and cerebrovascular disease at waitlist entry. Multivariate analysis found statistically significant lower rates of transplantation for all (+)VAD groups compared with age-matched (-)VAD counterparts, with the 45- to 65-year-old (+)VAD group having the lowest transplantation rate (SHR = 0.62; P < .0005). Among (-)VAD patients, transplantation rates increased with increase in age., Conclusions: There is a statistically significant reduced rate of transplantation for patients with a VAD compared with those without a VAD, with the lowest rate among those of ages 45 to 65 years with a VAD. The increasing prevalence of this demographic and the deprioritization of VADs in the new heart allocation criteria have the potential to further exacerbate this difference., (© 2020 Wiley Periodicals LLC.)

Background: Cytomegalovirus (CMV) infection has been associated with increased risk of mortality, cardiac allograft vasculopathy, and de novo malignancy following heart transplantation in prior institutional reports. This study examines the impact of the recipient and donor CMV status on heart recipients in the United States., Methods: Adult heart transplant recipients were identified in the OPTN registry between 2005-2016. Recipients were stratified based on the recipient (R) and donor (D) CMV serologic status (+/-). The primary endpoint was survival 5-years after transplantation. The secondary endpoint was cardiac allograft vasculopathy 5-years after transplantation. Separate Cox proportional hazards regression models were developed to evaluate independent associations between CMV status and each of the study endpoints., Results: A total of 21 878 recipients met the inclusion criteria. The breakdown of study arms by CMV serologic status was R-/D- = 3412, R+/D- = 4939; R-/D+ = 5230, and R+/D+ = 8,297. Five-year survival estimates were similar across groups (77-79%). CMV status was associated with increased mortality at 5-years (23%-41% increased risk) which was most evident in the first 3 months. The use of valganciclovir was associated with decreased risk of mortality (HR 0.56; 95% CI, 0.52-0.60). The cumulative incidence of cardiac allograft vasculopathy (R-/D- = 31%, R+/D- = 30%, R-/D+ = 31%, and R+/D+ = 30%) was similar across groups., Conclusions: CMV seropositivity at the time of transplantation is associated with increased long-term risk of mortality. Chemoprophylaxis with antivirals seems to mitigate this risk. There was no association with an increased risk of allograft vasculopathy., (© 2020 Wiley Periodicals, Inc.)

Background: The use of left ventricular assist devices (LVADs) as a bridge to heart transplantation has increased rapidly over the last 2 decades. We aim to explore the effect of pretransplant systemic and device-related complications on posttransplant survival for patients bridged with LVADs., Materials and Methods: The United Network of Organ Sharing (Organ Procurement and Transplantation Network) database was queried for all adult heart transplant recipients (aged ≥ 18 y) transplanted from April 1, 2015, to June 31, 2018. Device-related complications included thrombosis, device infection, device malfunction, life-threatening arrhythmia, and other device complications. Systemic complications included a new dialysis need or ventilator dependence between the time of listing and transplantation, transfusion, or systemic infection requiring treatment with intravenous antibiotics within 2 wk of transplantation., Results: A total of 2131 patients were identified as requiring LVAD support before transplantation. LVAD patients had high rates of preoperative systemic complications (53%) and high rates of device-related complications (42.7% experienced at least one device-related complication). Kaplan-Meier analysis revealed a significantly decreased 1-y survival for LVAD patients bridged to transplantation who experienced a pretransplant systemic complication (P = 0.041). Interestingly, preoperative device-related complications had no effect on 1-y posttransplantation survival (P = 0.93). Multivariate Cox modeling revealed that systemic complications were associated with a significantly increased risk of posttransplant mortality for LVAD patients (hazard ratio 1.45; P = 0.033)., Conclusions: Recipients who suffered a systemic complication while awaiting heart transplantation experienced higher short-term mortality rates. Device-related complications do not appear to impact posttransplantation outcomes., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Left ventricular assist devices (LVADs) are the most common mode of circulatory support for patients awaiting heart transplantation. Unfortunately, a fraction of these patients require pump exchange during their course for pump-related adverse events. This study examined whether LVAD exchanges affect posttransplantation outcomes., Methods: This study focused on adult patients in the Organ Procurement and Transplantation Network database who were bridged to transplant with a LVAD implanted between 2007 and 2017. Patients who underwent LVAD exchange were compared with those supported with a single device. The primary end point was all-cause mortality at 1, 2, and 5 years after transplantation. The impact of device exchange on risk-adjusted outcomes was examined using Cox proportional hazards models., Results: Among 8239 patients who met the inclusion criteria, there were 611 pump exchanges in 560 patients (7% of recipients). The pump exchange rate was 6.24 events per 100 patient-years. Survival at 5 years was lower for those who underwent LVAD exchange (69.4% vs 77.5%, log-rank P = .027). This finding was similar for risk-adjusted 5-year mortality (hazard ratio, 1.36; 95% confidence interval, 1.11 to 1.67; P = .003). Subgroup analysis revealed lower 5-year survival for female recipients who underwent LVAD exchange (55.4% vs 79.7%, log-rank P < .001). The interaction between female sex and LVAD exchange was associated with increased risk-adjusted 5-year mortality (hazard ratio, 1.65; 95% confidence interval, 1.05 to 2.59; P = .030)., Conclusions: Recipients who underwent pump exchange while awaiting heart transplantation had a higher mortality compared with those on a primary device. Subgroup analysis revealed a marked increase in mortality of female recipients who experienced LVAD exchange., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Phenotypic matching in heart transplantation, where donors and recipients are matched based on physical characteristics, has been previously limited to only analyzing individual variables such as sex and age. This study examines the effects of phenotypic matching utilizing multiple factors simultaneously., Methods: Adult patients undergoing heart transplantation between 2006 and 2016 were identified from the Organ Procurement and Transplantation Network database. Phenotypic matching was defined based on six factors: body mass index difference >30%, age difference >30%, height difference >7%, non-identical ABO blood grouping, race, and sex. A value between 0 and 1 mismatched characteristics was considered phenotypically like matching, whereas 2-6 mismatches was considered phenotypically unlike matching. The primary study endpoint was 1-year survival. Risk-adjusted mortality was examined with multivariable Cox regression models., Results: During the study period, 20,052 adult patients underwent heart transplantation, of whom 9595 (47.9%) were phenotypically like and 10,457 (52.1%) were phenotypically unlike matched. No differences in 1-year survival were seen between like and unlike matched patients (risk-adjusted odds ratio 1.05, 95% confidence interval 0.96-1.15, P = .305) after controlling for clinically relevant covariates. Subgroup analyses did not demonstrate survival differences after stratification based on hospital transplant volume and initial waitlist status. Phenotypically like matched patients had longer waiting times compared with unlike matched patients overall (225 days vs 192 days, P < .001)., Conclusions: Waiting for a phenotypically matched heart provides no survival benefit and exposes patients to prolonged waitlist times. These findings challenge the notion that a perfect donor heart exists, when in fact this concept may be a misnomer., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Left ventricular assist devices (LVADs) are an effective therapy in bridging patients with end-stage heart failure to heart transplantation. The aim of this study was to identify the role of race in survival of patients bridged to heart transplantation with a LVAD., Methods: The United Network of Organ Sharing database was queried for all adult heart transplant recipients (age 18 years or older) who were bridged to transplantation with a LVAD from 2005 to 2018. Patients were stratified based on their race, with whites as the reference group. Demographic characteristics, 5-year survival, and graft failure after transplantation were assessed with χ 2 test, analysis of variance, Kaplan-Meier survival analyses, log-rank tests, and Cox proportional hazards modeling or logistic regression modeling as appropriate., Results: Patients (N = 6476) successfully bridged with a LVAD to heart transplantation were identified. There were 4263 whites, 1536 African Americans, 508 Hispanics, and 169 Asians. Compared with whites, African Americans had higher body mass indexes, were more likely to be women, pay with private insurance, and be working for income at the time of transplantation. African Americans were found to have increased odds of graft failure (odds ratio 1.27, P = .048) compared with whites. In addition, African Americans were found to have increased risk of mortality at 5 years (hazard ratio 1.26, P = .003)., Conclusions: The African American race is associated with increased rates of graft failure after transplantation and decreased 5-year survival compared with the white race. Given these findings, directed clinical attention may be warranted in African American patients bridged to heart transplantation with a LVAD., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The impact of center volume on heart transplantation is widely recognized and serves as a benchmark for certification and reimbursement., Study Aims: Study sociodemographic variables associated with access to high-volume centers and substantiate the importance of extending access to underserved populations., Methods: This study focused on adults undergoing heart transplantation between 2006 and 2015. Centers were clustered into terciles (>25, 14-25, or <14 transplants per year) and factors associated with receiving care in different terciles were identified through multinomial regression., Results: During the study period, 18 725 patients were transplanted at 145 centers. Younger age (<30 years) (P = .005), lower educational level (P < .001), and government-based insurance (P < .001) were associated to lower odds of receiving care at a high-volume center. These centers had higher risk recipients and accepted organs from higher risk donors, when compared to intermediate- and low-volume centers. Receiving care at high (odds ratio [OR], 1.212; P = .017) and intermediate-volume centers (OR, 1.304; P = .001) was associated with greater odds of 1-year survival when compared with low-volume centers., Conclusion: Social, demographic, and geographic factors affect access to high- and intermediate-volume centers. High-volume centers tolerate more risk while providing excellent survival. Awareness of this impact should prompt an extension of access to care for underserved patient populations., (© 2019 Wiley Periodicals, Inc.)

This article reviews the surgical considerations of cardiac allograft rejection after heart transplantation and describes current treatment modalities for the failing graft. Cardiac allograft rejection can be a moribund diagnosis, especially when it is acute and high grade. It is broadly categorized into hyperacute, acute cellular, and antibody-mediated rejection. Treatment includes a multitude of medical and immunomodulation therapies for graft recovery. Severe rejection requires mechanical circulatory support for hemodynamic stability to maintain end-organ function. Retransplantation for graft loss is the ultimate therapy; however, it portends poor outcomes., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The use left ventricular assist devices (LVAD) as a bridge-to-transplant (BTT) has become a common modality to treat end-stage heart failure. We sought to examine the impact of BTT on long-term survival and quality of life after heart transplant. The population was all adult patients undergoing isolated heart transplantation in the United States between 2007 and 2017. Inclusion criteria covered BTT patients with a LVAD (only Heartmate II [HMII] or HeartWare Ventricular Assist System [HVAD]) and compared these with patients undergoing de novo heart transplantation. Our primary end-point was survival at 1, 2, and 5 years. Secondary end-points were functional status, return to work, and rates of hospital readmission and graft rejection. Unconditional and conditional survival was estimated with the Kaplan-Meier method. The independent influence of BTT on risk-adjusted mortality was determined using Cox proportional hazards models. In this period, 5,584 patients were bridged with an LVAD and 12,295 underwent de novo transplantation. Unconditional survival was 2% higher in de novo patients at 1, 2, and 5 years. After risk adjustment, BTT was associated with increased mortality at each time point. Unadjusted 5 year survival, conditional on 90 day survival, was similar between groups (82.6% vs. 83.4%; p = 0.15). Functional status, return to work, and unadjusted rates of hospital readmission and graft rejection were similar at 1, 2, 5 years. Bridge-to-transplant with LVADs provides excellent survival and similar quality of life to that of patients undergoing de novo heart transplantation. Bridge-to-transplant patients experience a slightly higher mortality rate within 90 days of transplantation.

Background: Heart transplant recipients of traumatically brain-injured (TBI) donors have been reported to have inferior survival and increased rates of cardiac allograft vasculopathy in single-center studies. This study sought to examine the impact of TBI donors on outcomes after heart transplantation across all transplantation centers., Methods: We identified all adult heart transplants performed during 2007-2016 in the OPTN database. Recipients were dichotomized based on donor cause of death (TBI versus non-TBI), propensity-scored across 22 variables with known associations with mortality, and matched 1:1 without replacement. The primary endpoint was all-cause mortality. Secondary endpoints were conditional survival and rates of cardiac allograft vasculopathy., Results: In total, 20,244 patients underwent heart transplantation. TBI was the primary cause of death in 53.4% of donors (10,816/20,244), and among TBI donors, blunt injury (59.6%; 6443/10,816) and gunshot wound (35%; 3781/10,816) were the most common mechanisms of injury. Propensity matching generated 6919 pairs (all absolute mean differences < 0.07). Risk-adjusted survival was similar between recipients of TBI donors and non-TBI donors at 5 y (78.1% versus 77.5%, log-rank P = 0.34). Risk-adjusted survival conditional on 1-y survival was also similar at 5 y (86.2% versus 86.1%, log-rank P = 0.74). The 5-y risk-adjusted rates of cardiac allograft vasculopathy did not differ either (30.6% versus 30.4%; log-rank P = 0.78)., Conclusions: In the largest analysis of TBI donors in heart transplantation, we found similar survival and rates of cardiac allograft vasculopathy to those who received hearts from non-TBI donors out to 5 y. These findings should allay concerns over continued transplantation with this unique donor population., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Left ventricular assist devices are increasingly used as bridge-to-transplantation in eligible patients. The HeartMate 3 (HM3; Abbott Laboratories, Abbot Park, IL) is the latest device to obtain US Food and Drug Administration approval as bridge-to-transplantation. This study examines early outcomes of transplant recipients after HM3 in comparison with recipients bridged with the HeartMate 2 (HM2; Abbott Laboratories) and HeartWare Ventricular Assist System (HVAD; Medtronic, Minneapolis, MN) devices., Methods: Using the Organ Procurement and Transplantation Network database, we identified all adult patients who were slated for bridge-to-transplantation with a continuous-flow left ventricular assist devices (HM2, HVAD, or HM3) between April 1, 2015 and January 31, 2018. The primary endpoint was all-cause mortality 6 months after transplantation. The independent influence of the bridging device on outcomes was determined using Cox proportional hazard models., Results: Patients (N = 1,978) were successfully bridged to transplantation with the HM2 (n = 881), HVAD (n = 920), or HM3 (n = 177) device. Six-month mortality rates were similar across these devices (HM2, 5.9%; HVAD, 7.7%; HM3, 4.7%; log-rank p = 0.30). On average HM2 patients were on a left ventricular assist device for 2 months longer (p < 0.01). The HVAD had the lowest rate of device exchange before transplant (p = 0.01). The HM3 had no events of pump thrombosis (p < 0.01). HVAD patients had the lowest rate of device malfunction before to transplant (p < 0.01). Panel reactive antibodies at the time of transplantation were lower for HM3 patients (p < 0.01); however rates of graft rejection at 6 months were not different (p = 0.25)., Conclusions: The HM3 device provides excellent early outcomes as a bridge to transplantation and may be associated with a reduction in comorbidities. Longer follow-up is needed to better define differences between durable left ventricular assist devices., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Sensitization has been associated with worse outcomes following heart transplantation (HTx). The use of ventricular assist devices (VAD) is a risk factor for the development of sensitization. We investigated the impact of left ventricular assist devices (LVAD) and sensitization in HTx recipients., Methods: We queried the UNOS database for all heart transplants performed from January 2000 through December 2016. Patients were considered highly sensitized and included if panel-reactive antibody (PRA) activity was 25% or higher. Patients were separated by pretransplant LVAD utilization and subgroup analysis was performed by device type (HeartMate II or HeartWare). Outcomes included Kaplan-Meier survival and episodes of rejection within 1 year of HTx., Results: Of 18 009 recipients, 2434 (14%) were highly sensitized. 1055 (43.3%) were bridged with a VAD. In multivariate analysis, LVAD use did not impact 1-year (hazards ratio [HR], 1.30; P = 0.052) or 5-year survival (HR, 1.18; P = 0.112) in highly sensitized recipients. Furthermore, episodes of rejection were not affected by LVAD status (P = 0.765). Of the 1055 sensitized LVAD-bridged transplant recipients, 624 (59%) were implanted with a HeartMate II and 99 (9.4%) were bridged with a HeartWare device. In multivariate analysis, no differences were observed in 1-year survival (HR, 0.86; P = 0.664), 5-year survival (HR, 1.35; P = 0.209), or episodes of rejection (P = 0.497)., Conclusions: The use of ventricular assist devices did not impact survival or rejection within 1 year of HTx in highly sensitized patients. Highly sensitized recipients have similar outcomes regardless of prior LVAD support or type of LVAD used as a bridge to transplantation., (© 2019 Wiley Periodicals, Inc.)

This case report describes an unusual case of spontaneous iliac intramuscular hematoma after a heart transplant secondary to valvular cardiomyopathy. A spontaneous retroperitoneal hematoma occurring after a heart transplant is rare, but can occur when the patient is on immunosuppressive medications. This could be secondary to the medications' ability to suppress the immune system and cause antiplatelet therapylike effects. Spontaneous retroperitoneal hematomas can cause significant patient morbidity, sometimes even causing immobility; however, a high index of suspicion with early recognition and immediate intervention can reduce the sequelae. Although the occurrence of a spontaneous retroperitoneal hematoma after a heart transplant is rare; there should be a high index of suspicion in cases where the patient is elderly, has experienced rejection episodes, and is taking immunosuppressants, or in cases where the patient is additionally on anticoagulation and antiplatelet therapy.

Objectives: Increased numbers of end-stage heart failure patients and improved technology have led to increased use of left ventricular assist devices as a viable alternative to heart transplants. Given the current economic climate, we compared costs of heart transplant versus device placement., Materials and Methods: Medical records of patients who received heart transplants or left ventricular assist devices were cross-referenced with institutional financial data. The device cohort was limited to those receiving durable (not temporary) devices. Index admission, 1-year readmission, and overall 1-year charges were compared using standard statistical methods., Results: Of 184 identified patients with end-stage heart failure surgical therapy, 121 received left ventricular assist devices, 43 had heart transplants, and 20 received left ventricular assist devices as bridge to heart transplant; these latter patients were excluded from our analyses. At index admission, mean charges were $863 433 ± $398 427 for device patients and $725 877 ± $488 685 for transplant patients (P = .05). One-year mean readmission rates were similar (4.65/transplant patient and 4.53/device patient; P = .94), with corresponding 1-year survival rates of 87.8% and 78.0% (P = .04). Total readmission charges during year 1 were $169 732 ± $242 366 for device patients and $201 682 ± $297 565 for transplant patients (P = .08), with corresponding overall charges at 1 year of $1 029 732 ± $450 498 and $927 559 ± $562 404 (P = .49)., Conclusions: During the first year, heart transplant and left ventricular assist device placement have similar costs. Initial index admission costs seem to favor heart transplant, with device pump costs accounting for some of the difference. From a 1-year survival perspective, heart transplant may be more effective; however, with lack of suitable donors, left ventricular assist devices are valuable in the armamentarium of advanced heart failure surgical options.

Concerns exist regarding orthotropic heart transplantation in hepatitis C virus (HCV) seropositive recipients. Thus, a national registry was accessed to evaluate early and late outcome in HCV seropositive recipients undergoing heart transplant. Retrospective analysis of the United Network for Organ Sharing registry (1991 to 2014) was performed to evaluate recipient profile and clinical outcome of patients with HCV seropositive (HCV +ve) and seronegative (HCV -ve). Adjusted results of early mortality and late survival were compared between cohorts. From 23,507 patients (mean age 52 years; 75% men), 481 (2%) were HCV +ve (mean age 52 years; 77% men). Annual proportion of HCV +ve recipients was comparable over the study period (range 1.3% to 2.7%; p = 0.2). The HCV +ve cohort had more African-American (22% vs 17%; p = 0.01), previous left ventricular assist device utilization (21% vs 14%; p <0.01) and more hepatitis B core Ag+ve recipients (17% vs 5%; p <0.01). However, both cohorts were comparable in terms of extracorporeal membrane oxygenator usage (p = 0.7), inotropic support (p = 0.2), intraaortic balloon pump (p = 0.7) support, serum creatinine (p = 0.7), and serum bilirubin (p = 0.7). Proportion of status 1A patients was similar (24% HCV + vs 21% HCV -); however, wait time for HCV +ve recipients were longer (mean 23 vs 19 days; p <0.01). Among donor variables, age (p = 0.8), hepatitis B status (p = 0.4), and Center for Diseases Control high-risk status (p = 0.9) were comparable in both cohorts. At a median follow-up of 4 years, 67% patients were alive, 28% died, and 1.1% were retransplanted (3.4% missing). Overall survival was worse in the HCV+ cohort (64.3% vs 72.9% and 43.2% vs 55% at 5 and 10 years; p <0.01), respectively. Late renal (odds ratio [OR] 1.2 [1 to 1.6]; p = 0.02) and liver dysfunction (odds ratio 4.5 [1.2 to 15.7]; p = 0.01) occurs more frequently in HCV +ve recipients. On adjusted analysis, HCV seropositivity is associated with poorer survival (hazard ratio for mortality 1.4 [1.1 to 1.6]; p <0.001). In conclusion, a small proportion of patients receiving a heart transplant in the United States have hepatitis C. Despite comparable preoperative hepatic function, hepatitis C seropositive recipients demonstrate poorer long-term survival., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: This study evaluated whether minority orthotopic heart transplant (OHT) recipients tend to be transplanted at worse performing centers., Methods and Results: OHT recipients between 2000 and 2010 were identified in the United Network for Organ Sharing database and stratified by race. Center performance was evaluated using observed-to-expected mortality ratios that were calculated using validated indexes for recipient and donor risk in OHT. The primary outcome was 1-year post-OHT mortality. A total of 102 centers performed OHT in 18 085 patients. Blacks had higher unadjusted 1-year mortality, which was confirmed after risk adjustment. Blacks had increased risk-adjusted mortality at poor performing centers (observed-to-expected mortality ratio, >1.2; odds ratio, 1.37 [95% confidence interval, 1.12-1.69]; P=0.002) and a strong trend toward increased mortality at excellent performing centers (observed-to-expected mortality ratio, <0.8; odds ratio, 1.42 [95% confidence interval, 0.99-2.02]; P=0.06). A higher proportion of blacks were treated at centers with higher-than-expected mortality (56.4% versus 47.1% whites versus 48.1% Hispanics; P<0.001), a finding that persisted after adjusting for insurance type and highest education level. In addition, there was a positive correlation between the percentage of blacks and observed-to-expected mortality ratios at the center level (r=0.32; P=0.001). In multivariable analysis incorporating immunologic and socioeconomic variables, there was no clear dominant source for the disparities in outcomes of OHT between races., Conclusions: Blacks have a propensity to be transplanted at worse performing centers; however, center effect alone does not explain the mortality difference between ethnicities. Although referral of minorities to better performing centers would improve absolute survival, it would not likely eliminate the racial disparities that exist in OHT outcomes., (© 2015 American Heart Association, Inc.)

Introduction: The impact of induction immunosuppression on long-term survival in heart transplant recipients is unclear. Over the past three decades, practices have varied as induction agents have changed and experiences grew. We sought to evaluate the effect of contemporary induction immunosuppression agents in heart transplant recipients with the primary endpoint of survival, utilizing national registry data., Methods: We queried the United Network for Organ Sharing (UNOS) data registry for all heart transplants from 1987 to 2012. We restricted our analysis to adult (≥18 yr) recipients performed from 2001-2011 (to allow for the potential for a minimum of 12 months post-transplant follow-up) who received either: no antibody based induction (NONE) or the contemporary agents (INDUCED) of either: basiliximab/daclizumab (IL-2Rab), alemtuzumab, or ATG/ALG/thymoglobulin. Kaplan-Meier estimates of the survival function as well as Cox proportional hazards models were utilized., Results: Of the 17 857 heart transplants that met the inclusion criteria, there were 4635 (26%) reported deaths during the follow-up period. There were 8216 (46%) patients who were INDUCED. Of the INDUCED agents, 55% were IL-2Rab, 4% alemtuzumab, and 40% ALG/ATG/thymoglobulin. Donor and recipient characteristics were evaluated. Overall, being INDUCED did not significantly affect survival in univariable (p = 0.522) and multivariable (p = 0.130) Cox models as well as a propensity score adjusted model (p = 0.733). Among those induced, ATG/ALG/thymoglobulin appeared to have superior survival as compared with IL-2Rab (log-rank p = 0.007, univariable hazard ratio [HR] = 0.886; 95% CI: 0.811-0.968; p = 0.522). However, in a multivariable Cox model that adjusted for recipient age, VAD, BMI, steroid use, CMV match, and ischemic time, the hazard ratio for ALG/ATG/thymoglobulin vs. IL-2Rab was no longer statistically significant (HR = 0.948; 95% CI: 0.850-1.058; p = 0.341)., Conclusion: In a contemporary analysis of heart transplant recipients, an overall analysis of induction agents does not appear to impact survival, as compared to no induction immunosuppression. While ALG/ATG/thymoglobulin appeared to have a beneficial effect on survival compared to IL-2Rab in the univariable model, this difference was no longer statistically significant once we adjusted for clinically relevant covariates., (© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Diaphragmatic hernias are a known complication of explanting a left ventricular assist device. The increasing use of left ventricular assist devices has resulted in an increased risk of this complication. We present the case of a patient who presented with diaphragmatic hernias on routine follow-up after a heart transplant. A left thoracotomy was performed to expose and reduce the hernia using a bovine pericardial patch to repair the defect. This biomaterial represents a viable alternative to traditional GORE-TEX patches with the probability of decreased infectious complications.

Background. The 2018 Organ Procurement and Transplantation Network (OPTN) heart allocation policy change prioritizes patients bridged to transplant with mechanical circulatory support (MCS) devices, including extracorporeal membrane oxygenation (ECMO). As a result, the use of ECMO has significantly increased. Methods. We reviewed the OPTN database for adult patients undergoing heart transplant after bridge with ECMO between January 1st 2000 and October 18th 2018. We excluded patients with ≥180 days of ECMO duration, prior transplants, and those using additional MCS devices. Survival and morbidity outcomes of patients with ≥7 days of pre-transplant ECMO were compared to those of patients with <7 days. Results. Of 362 eligible transplant recipients, 163 (45%) utilized <7 days of pre-transplant ECMO and 199 (55%) utilized ≥7 days. Those with ≥7 days were younger (median age: 43 [28–54] vs. 50 [36–57] years, p = 0.006) and more likely to have temporary waitlist inactivity (18% vs. 7%, p = 0.003) with significantly longer duration of ECMO use (median: 14 [9–24] vs. 4 [2–5] days, p < 0.001). Patients with ≥7 days of ECMO had comparable survival to those with <7 days at one year (81.1% vs. 79.4%, p = 0.64) and five years (61.1% vs. 49.3%, p = 0.27). After adjustment for clinically relevant variables, duration of ECMO ≥7 days did not increase mortality at five years (HR = 0.90, p = 0.59). Conclusions. Longer duration of ECMO (≥7 days vs. <7 days) among patients successfully bridged to transplant is not associated with increased mortality or selected adverse outcome, including graft failure or rejection, at up to five years. [ABSTRACT FROM AUTHOR]

Background: Destination left ventricular assist device placement is increasing as a result of donor shortages and changing patient attitudes. As organ shortages become critical, LVAD programs become fundamental even in more remote regions of the world including island states. Here, we provide a look into the current state and availability of LVAD programs in island states. Main body: A narrative review was performed using the World Health Organization Global Index Medicus and PubMed/MEDLINE databases to identify articles describing the island states having reported LVAD placements and programs. Additionally, INTERMACS reports were used. Data were retrieved and a review is presented describing the current state of LVADs in island states. The Caribbean region as a whole has a heart failure (HF) prevalence of 814 per 100,000 and Oceania 667 per 100,000 people. We estimate that over 3000 people in these islands need either a heart transplant or an LVAD. Short conclusion: For HF patients living in island regions, special attention should be paid to the inability of having access to specialized mainland medical care. The continuous quest for a solution to HF in island regions should include the establishing of high-quality LVAD programs in a transfer-network centralized/regionalized system to care for those patients not candidates for long-distance air-bridging. [ABSTRACT FROM AUTHOR]

Aims The adult human sinoatrial node (SAN) has a specialized fibrotic intramural structure (35-55% fibrotic tissue) that provides mechanical and electrical protection from the surrounding atria. We hypothesize that late gadolinium-enhanced cardiovascular magnetic resonance (LGE-CMR) can be applied to define the fibrotic human SAN structure in vivo. Methods and results LGE-CMR atrial scans of healthy volunteers (n olu, 23-52 y.o.) using a 3 Tesla magnetic resonance imaging system with a spatial resolution of 1.0mm³ or 0.625 x 0.625 x 1.25mm³ were obtained and analysed. Percent fibrosis of total connective and cardiomyocyte tissue area in segmented atrial regions were measured based on signal intensity differences of fibrotic vs. non-fibrotic cardiomyocyte tissue. A distinct ellipsoidal fibrotic region (length: 23.6 ± 1.9mm; width: 7.2 ± 0.9mm; depth: 2.9 ± 0.4mm) in all hearts was observed along the posterior junction of the crista terminalis and superior vena cava extending towards the interatrial septum, corresponding to the anatomical location of the human SAN. The SAN fibrotic region consisted of 41.9 ± 5.4% of LGE voxels above an average threshold of 2.7 SD (range 2-3 SD) from the non-fibrotic right atrial free wall tissue. Fibrosis quantification and SAN identification by in vivo LGE-CMR were validated in optically mapped explanted donor hearts ex vivo (n ivo, 19-65 y.o.) by contrast-enhanced CMR (9.4 Tesla; up to 90 mm³ resolution) correlated with serial histological sections of the SAN. Conclusion This is the first study to visualize the 3D human SAN fibrotic structure in vivo using LGE-CMR. Identification of the 3D SAN location and its high fibrotic content by LGE-CMR may provide a new tool to avoid or target SAN structure during ablation. [ABSTRACT FROM AUTHOR]

Background Recommended structured clinical practices including implant technique, anti-coagulation strategy, and pump speed management (PREVENT [ PREVEN tion of HeartMate II Pump T hrombosis Through Clinical Management] recommendations) were developed to address risk of early (<3 months) pump thrombosis (PT) risk with HeartMate II (HMII; St. Jude Medical, Inc. [Thoratec Corporation], Pleasanton, CA). We prospectively assessed the HMII PT rate in the current era when participating centers adhered to the PREVENT recommendations. Methods PREVENT was a prospective, multi-center, single-arm, non-randomized study of 300 patients implanted with HMII at 24 participating sites. Confirmed PT (any suspected PT confirmed visually and/or adjudicated by an independent assessor) was evaluated at 3 months (primary end-point) and at 6 months after implantation. Results The population included 83% men (age 57 years ± 13), 78% destination therapy, and 83% Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) Profile 1–3. Primary end-point analysis showed a confirmed PT of 2.9% at 3 months and 4.8% at 6 months. Adherence to key recommendations included 78% to surgical recommendations, 95% to heparin bridging, and 79% to pump speeds ≥9,000 RPMs (92% >8,600 RPMs). Full adherence to implant techniques, heparin bridging, and pump speeds ≥9,000 RPMs resulted in a significantly lower risk of PT (1.9% vs 8.9%; p < 0.01) and lower composite risk of suspected thrombosis, hemolysis, and ischemic stroke (5.7% vs 17.7%; p < 0.01) at 6 months. Conclusions Adoption of all components of a structured surgical implant technique and clinical management strategy (PREVENT recommendations) is associated with low rates of confirmed PT. [ABSTRACT FROM AUTHOR]

Ventricular assist devices (VADs) are commonly used mechanical circulatory support for bridge to transplant therapy in end-stage heart failure; however, it is not understood how VADs influence incidence of waitlist inactive status. We sought to characterize and compare waitlist inactivity among patients with and without VADs. Using the Organ Procurement and Transplantation Network database, we investigated the VAD's impact on incidence and length of inactive periods for heart transplant candidates from 2005 through 2018. We compared median length of inactivity between patients with and without VADs and investigated inactivity risk with time-to-event regression models. Among 46,441 heart transplant candidates, 32% (n = 14,636) had a VAD. Thirty-eight percent (n = 17,873) of all patients experienced inactivity, of which 42% (7538/17,873) had a VAD. Median inactivity length was 31 d for patients without VADs and 62 d for VAD patients (P < 0.0005). Multivariable analysis showed no significant difference in risk of inactivity for deteriorating conditions between patients with and without VADs after controlling for demographic and baseline clinical variables. A larger proportion of patients without VADs were inactive for deteriorating conditions than VAD patients (54%, n = 8242/15, 221 versus 32%, n = 3583/11,086, P < 0.001). Ten percent (1155/11,086) of VAD patients' inactive periods were for VAD-related complications. Although VAD patients were inactive longer and had an overall increased risk of any-cause inactivity, their risk of inactivity for deteriorating condition was not significantly different from patients without VADs. Furthermore, VAD patients had a smaller proportion of inactivity periods due to deteriorating conditions. Thus, VADs are protective from morbidity for waitlist patients. • Patients with ventricular assist devices had no statistically significant difference in risk of waitlist inactivity for deterioration of their condition. • "Deterioration of Condition" and "VAD-related Complications" made up a smaller proportion of inactive periods for patients with ventricular assist devices. • Ventricular assist device implantation was a major contributor to waitlist inactivity for patients who were implanted while on the waitlist. [ABSTRACT FROM AUTHOR]

Introduction: Optimal care of patients in end-stage heart failure is based on multidisciplinary care, setting accurate prognostic expectations, and offering realistic treatment options. We sought develop prognostic tools that can predict the probability of receiving a heart transplant based solely on factors available at the time of waitlist registration. Methods: We identified all candidates registered for heart transplantation between 2010 and 2016 in the United States. Nonparametric cumulative incidence estimates were generated for the following competing outcomes: transplantation, medical improvement, and death or worsening condition. The primary study endpoint was receiving a heart transplant 30-days, 90-days, and 1-year after registration. Multivariable logistic regression models were developed using factors available at the time of listing. Nomograms were generated for each time point to manually calculate predicted probability of allocation. Results: Over the study period, 23,706 adult patients were registered for heart transplantation. At one-year, 52% survived to transplant and 11% died or were removed from the waitlist for worsening condition, while 32% were still waiting for an organ. A candidate's initial listing status, blood group, geographical region, and body mass index had the strongest association to transplantation. The models had a robust performance in the internal validation cohort. Model discrimination deteriorated slightly as time from registration passed (c-statistics: 30-day=0.817, 90-day=0.794, and 1-year=0.769). Conclusions: Heart allocation may be reliably predicted in adult transplant candidates. These models can help focus conversations on expected prognosis and earlier consideration of alternative treatment modalities. Future studies will validate and update this tool to provide optimal care for patients. [ABSTRACT FROM AUTHOR]