Search

BACKGROUND The number of adult congenital heart disease (ACHD) patients requiring heart transplantation (HT) continues to grow, and if they survive the first year after transplant, their long-term survival is at least equivalent to non-ACHD patients. The 1-year survival of ACHD patients with HT remains lower than non-ACHD patients. We evaluated the affect of transplant center volume on 1-year survival of ACHD patients. We analyzed United Network of Organ Sharing patients (age ≥18 years) who underwent their first orthotopic HT between January 1, 2000, and December 31, 2015, to assess the association between transplant center volume and 1-year survival of ACHD patients. RESULTS We identified 827 ACHD patients at 113 centers who underwent HT during the study period. The average age of the recipients and donors was 36 ± 13 years (60% men and 84% Caucasian) and 28 ± 11 (63% men and 66% Caucasian), respectively. Of the ACHD patients undergoing HT, 27% (n = 60) were done at low-volume centers, 30% (n = 10) were reported at high-volume centers, and the remaining (n = 43) were at medium-volume centers. A total of 96 patients died within 30 days, including 37 (16.7%) at low-volume, 37 (10.2%) at medium-volume, and 22 (9.0%) at high-volume centers (p = 0.019). The average unadjusted Kaplan-Meier 30-day survival at low-volume centers was 83% ± 2%, which was significantly lower than medium-volume (90% ± 1%) and high-volume (91% ± 2%) centers (log-rank p < 0.05). Within 1 year, 154 patients had died, including 56 (36.4%) at low-volume, 60 (38.9%) at medium-volume, and 38 (24.7%) at high-volume centers (p = 0.011). Average unadjusted Kaplan-Meier 1-year survival at low-volume centers was 75% ± 3%, which was significantly lower than medium-volume (83% ± 2%) and high-volume (84% ± 2%) centers (log-rank p < 0.05). CONCLUSIONS The 30-day and 1-year survival of ACHD patients undergoing HT is partly influenced by overall transplant center volume and, potentially, volume of ACHD HTs, with low-volume centers performing poorly relative to medium-volume and high-volume centers. The role of peri-operative care and multidisciplinary management in improving survival at low-volume centers required further investigations.

Right ventricular (RV) failure is a source of morbidity and mortality after left ventricular assist device (LVAD) implantation. In this study we sought to define hemodynamic changes in afterload and RV adaptation to afterload both early after implantation and with prolonged LVAD support.We reviewed right heart catheterization (RHC) data from participants who underwent continuous-flow LVAD implantation at our institutions (n = 244), excluding those on inotropic or vasopressor agents, pulmonary vasodilators or additional mechanical support at any RHC assessment. Hemodynamic data were assessed at 5 time intervals: (1) pre-LVAD (within 6 months); (2) early post-LVAD (0 to 6 months); (3) 7 to 12 months; (4) 13 to 18 months; and (5) very late post-LVAD (18 to 36 months).Sixty participants met the inclusion criteria. All measures of right ventricular load (effective arterial elastance, pulmonary vascular compliance and pulmonary vascular resistance) improved between the pre- and early post-LVAD time periods. Despite decreasing load and pulmonary artery wedge pressure (PAWP), RAP remained unchanged and the RAP:PAWP ratio worsened early post-LVAD (0.44 [0.38, 0.63] vs 0.77 [0.59, 1.0], p0.001), suggesting a worsening of RV adaptation to load. With continued LVAD support, both RV load and RAP:PAWP decreased in a steep, linear and dependent manner.Despite reducing RV load, LVAD implantation leads to worsened RV adaptation. With continued LVAD support, both RV afterload and RV adaptation improve, and their relationship remains constant over time post-LVAD. These findings suggest the RV afterload sensitivity increases after LVAD implantation, which has major clinical implications for patients struggling with RV failure.

Background The lung allocation score (LAS) has changed organ allocation for lung transplantation in the United States. Previous investigations of transplant recipients reported an association between high LAS and an increased risk of death after lung transplantation. We hypothesize that a high LAS predicts survival in lung transplant recipients with cystic fibrosis (CF) in the United Network for Organ Sharing Scientific Registry of Transplant Recipients database. Methods A cohort study was conducted of 1,437 U.S. adult lung transplant recipients with CF from May 1, 2005, through December 31, 2012. The cohort was divided into a high-risk group and a low-risk group based on LAS. Survival data were examined using Kaplan-Meier estimates and Cox proportional hazard models to compare survival. The primary outcome was adjusted survival at 1 year after lung transplantation. Results The high-risk group of 318 patients with a median LAS of 69.6 (interquartile range 56.3–87.2) was compared with a low-risk group of 1,119 patients with a median LAS of 38.8 (interquartile range 36.3–42.3). Patients in the high-risk group had a 41% increased relative risk of cumulative mortality at 1 year after transplantation compared with the low-risk group (16.1% vs 12.0%). After adjustment for known predictors of mortality, the risk of death at 1 year after transplantation remained elevated (hazard ratio=1.41; 95% confidence interval=1.00–2.01). The high-risk group had worse survival at 90 days and 2 years after lung transplantation. Conclusions High LAS are associated with worse survival in lung transplant recipients with CF.

Performing concomitant tricuspid valve procedures (TVPs) in left ventricular assist device (LVAD) patients with significant pre-operative tricuspid regurgitation (TR) is controversial, and no studies have been large enough to definitively guide therapy.Between January 2006 and September 2012, 2,196 patients with moderate to severe pre-operative TR from 115 institutions underwent implantation of a continuous-flow left ventricular assist device (LVAD) as reported by The Society of Thoracic Surgeons National Database. Of these, 588 (27%) underwent a concomitant TVP. Inverse probability weighting based on propensity score was used to adjust for differences between the LVAD alone and LVAD+TVP groups, and outcomes were compared.Most patients in the LVAD+TVP group underwent an annuloplasty alone (81.1%). Concomitant TVP did not affect risk of post-operative right VAD insertion (risk ratio [RR], 0.81; 95% confidence interval [CI], 0.49-1.36; p = 0.4310) or death (RR, 0.95; 95% CI, 0.68-1.33; p = 0.7658). However, TVP was associated with an increased risk for post-operative renal failure (RR, 1.53; 95% CI, 1.13-2.08; p = 0.0061), dialysis (RR, 1.49; 95% CI, 1.03-2.15; p = 0.0339), reoperation (RR, 1.24; 95% CI, 1.07-1.45; p = 0.0056), greater total transfusion requirement (RR, 1.03; 95% CI, 1.01-1.05; p = 0.0013), and hospital length of stay21 days (RR, 1.29; 95% CI, 1.16-1.43; p0.0001). Time on the ventilator and intensive care unit length of stay were also significantly prolonged for the LVAD+TVP group.Performing a concomitant TVP for continuous-flow LVAD patients with moderate to severe TR did not reduce early death or right VAD requirement and was associated with worse early post-operative outcomes. These data caution against routine concomitant TVP based solely on degree of pre-operative TR and suggest that additional selection criteria are needed to identify those patients in whom concomitant TVP may prevent post-operative right ventricular failure.

Background No consensus exists on the optimal heart preservative solution (HPS) for cardiac allograft preservation. The significance of varying degrees of acute ischemic necrosis (AIN) in early transplant biopsy specimens is unknown. We investigated the effects of HPS on early cardiac histopathology by developing a novel grading system of AIN. Methods A retrospective review of our institutional database of orthotopic heart transplants (OHT) identified hearts preserved with University of Wisconsin (UW) or Celsior solutions. AIN severity was graded on early post-transplant biopsy specimens. Primary stratification was by HPS. Multivariable models examined mortality, AIN grade, primary graft dysfunction (PGD), and right heart failure (RHF). Results From 1996 to 2010, 42 of 174 adult OHTs were preserved with UW and 132 with Celsior, from which 431 biopsy specimens were reviewed. UW and Celsior had similar 30-day ( p = 0.79) and 1-year mortality ( p = 0.92). Celsior was associated with significantly more AIN on the first ( p = 0.02) and second ( p = 0.04) specimens and persisted on multivariable analysis for the first (odds ratio, 2.93; 95% confidence interval, 1.26–6.83; p = 0.01) and second biopsy specimen (2.08; 0.99–4.34; p = 0.05). When stratified by AIN score, 30-day and 1-year mortality were similar ( p > 0.05). Adjusted analysis showed increasing AIN score on the first biopsy was strongly associated with an increased incidence of PGD (1.59; 1.02–2.47; p = 0.04) and RHF (2.45; 1.14–5.27; p = 0.02). Conclusions Our grading system provides a simple, reproducible method for determining AIN. UW is associated with less AIN than Celsior solution. Early biopsy ischemia is associated with PGD and RHF. AIN may have prognostic significance and its routine evaluation should be considered.

Despite significant advances in cardiac allograft preservation, the optimal preservative solution is unknown. We evaluated the impact of the most commonly used solutions in the USA, the University of Wisconsin solution (UW) and Celsior solution (CS), on outcomes after orthotopic heart transplantation (OHT).We retrospectively reviewed adult OHT recipients in the United Network for Organ Sharing (UNOS) database. Primary stratification was by preservation solution. The primary end-point was short-term survival (30 days and 1 year). Secondary end-points included common post-operative complications. Subgroup analysis was performed in high-risk allografts (donor age50 years or ischemic time4 hours). Risk-adjusted multivariate Cox proportional hazard regression was used to assess survival.From 2004 to 2009, 4,910 patients (3,107 UW and 1,803 CS) with sufficient preservation solution information for analysis underwent OHT. Baseline characteristics were well-matched between the two groups. UW was associated with a small but significantly improved survival compared with CS at 30 days (96.7% vs 95.4%, p = 0.02) and 1 year (89.6% vs 87.0%, p0.01). These survival differences persisted on multivariate analysis at 30 days (HR 1.47 [1.02 to 2.13], p0.05) and 1 year (HR 1.40 [1.14 to 1.73], p0.01). In the 1,455 patients with high-risk allografts, preservation with UW was associated with improved survival compared with CS at 30 days (94.3% vs 91.3%, p0.01) and at 1 year (84.2% vs 80.19%, p0.01), a difference that was significant according to multivariate Cox analysis at 30 days (HR 2.29 [1.39 to 3.76], p0.01) and 1 year (HR 1.61 [1.17 to 2.21], p0.01).Preservation with UW solution is associated with improved short-term survival compared with CS. Patients undergoing OHT with high-risk allografts have a similar survival benefit.

Background Socioeconomic factors such as education, health insurance, and race are known to affect health outcomes. The United Network for Organ Sharing (UNOS) database provides a large cohort of lung transplant (LTx) recipients in which to evaluate the effect of insurance on survival. Methods We retrospectively reviewed UNOS data for 11,385 adult primary LTx patients (1998–2008). Patients were stratified by insurance (private/self-pay, Medicare, Medicaid, and other type). All-cause mortality was examined with Cox proportional hazard regression incorporating 14 variables. The Kaplan-Meier method was used to model survival after LTx. Results Of 11,385 recipients, 7,100 (62.4%) had private insurance/self-pay; 2,966 (26.1%) had Medicare; 815 (7.2%) had Medicaid; and 504 (4.4%) had other type insurance. During the study, 4,943 patients (43.4%) died. Medicare and Medicaid patients had 7.0% and 8.1% lower 10-year survival than did private insurance/self-pay patients, respectively. Insurance did not affect 30-day, 90-day, or 1-year survival. Medicare and Medicaid patients had decreased survival at 3 years and longer. In multivariable analyses, Medicare (hazard ratio, 1.10; 95% confidence interval, 1.03–1.19) and Medicaid (hazard ratio, 1.29; 95% confidence interval, 1.15–1.45) significantly increased risk of death. When deaths in the first year were excluded, survival differences persisted. Conclusions This study represents the largest cohort evaluating the effect of insurance on post-LTx survival. Medicare and Medicaid patients have worse survival after LTx compared with private insurance/self-paying patients.

Background Lung transplant (LTx) candidates are frequently over or underweight. Few studies have examined recipient weight and outcomes after LTx. The United Network for Organ Sharing (UNOS) database provides an opportunity to examine outcomes related to body mass index (BMI) in a large cohort of LTx patients. Methods The UNOS data set was retrospectively reviewed for 11,411 adult primary LTx patients (1998 to 2008). Patients were stratified by recipient BMI (kg/m 2 ): less than 18.5 (underweight), 18.5 to 24.9 (normal), 25.0 to 29.9 (overweight), more than 30 (obese). All-cause mortality was examined with Cox proportional hazard regression incorporating 15 variables. Survival was modeled using the Kaplan-Meier method. Results Of 11,411 recipients, 1,355 (11.9%) were underweight, 4,998 (43.8%) were normal weight, 3,662 (62.1%) were overweight, and 1,396 (12.2%) were obese. During the study, 4,959 patients (43.5%) died. Mortality was significantly different between the strata, with incremental increases in death for each BMI category above or below normal. On multivariable analysis, BMI strata predicted death compared with normal weight. Risk of death was increased in recipients who were underweight (hazard ratio [HR], 1.14; 95% confidence interval [CI], 1.03–1.26; p = 0.01), overweight (HR, 1.06; 95% CI, 0.99–1.14; p = 0.1), and obese (HR, 1.16; 95% CI, 1.04–1.28; p = 0.005). Kaplan-Meier modeling showed a significant effect of BMI on survival; however, this effect was no longer significant when first-year deaths were excluded. Conclusions Mortality is higher in underweight, overweight, and obese LTx patients than in normal-weight controls. However, this effect appears to be governed by survival in the first year after LTx.

BACKGROUND: Infection is a significant source of morbidity and mortality after left ventricular assist device (LVAD) implantation. Newer generation continuous-flow (CF) LVADs are smaller, requiring smaller pump pockets and drive-line exit sites as compared with pulsatile-flow (PF) devices. With their recent adoption, CF device patients benefit from improved provider experience in the detection and treatment of infectious complications. Given these advances in design and experience, we examined the incidence of infectious complications in patients receiving CF and PF devices. METHODS: We reviewed patients who received CF or PF LVADs (June 2000 to May 2009) at our institution. Incidences and timing of systemic infections (bacteremia, sepsis, severe sepsis, septic shock), device-associated infections (drive-line, LVAD pocket, sternal wound) and non-device-associated infections (catheter-related bloodstream, pneumonia, urinary tract) were compared between devices. Primary outcomes were sepsis, severe sepsis, a composite of drive-line and LVAD pocket infection, and catheter-related bloodstream infection. RESULTS: Of 133 LVADs, 86 were CF. CF patients had lower pre-operative risk, more recent device implantation, and longer LVAD support time. Device type was highly correlated with reduced infections; however, on multivariate analysis, implantation date appeared to drive this association. Kaplan-Meier estimates of freedom from all primary outcomes were improved with more recent implantation (p < 0.05). On multivariate analysis, implantation date was predictive of all primary outcomes except severe sepsis, for which advanced age and worse Seattle Heart Failure Model score were predictive. CONCLUSION: In this institutional review of post-LVAD infections, a decrease in infectious complications in CF patients was likely related to increased provider experience associated with a more recent date of implantation.

The Lung Allocation Score (LAS) dramatically changed organ allocation in lung transplantation. The impact of this change on patient outcomes is unknown. The purpose of the study was to examine early mortality after lung transplantation under the LAS system.All patients undergoing first-time lung transplantation during the period from May 1, 2005 through April 30, 2008 were included in the study. The cohort was divided into quintiles by LAS. A high-risk group (LAS46) was comprised of the highest quintile, Quintile 5, and a low-risk group (LASor =46) included the lower quintiles, Quintiles 1 through 4. A time-to-event analysis was performed for risk of death after transplantation using Kaplan-Meier survival and Cox proportional hazards models.There were 4,346 patients who underwent lung transplantation during the study period. Patients in the high-risk group (LAS46) were more likely to have idiopathic pulmonary fibrosis (IPF; 52.9% vs 23.8%, p0.001) and diabetes (25.8% vs 16.8%, p0.001) and to require mechanical ventilatory support (15.4% vs 2.2%, p0.001) at the time of transplant as compared with patients in the low-risk group. One-year survival using the Kaplan-Meier product limit estimator was significantly worse in the high-risk group (75% vs 83%, p0.001 by log-rank test). Patients in the high-risk group were also found to have increased risk of death (hazard ratio 1.46, 95% confidence interval 1.24 to 1.73) compared with the low-risk group.Overall 1-year survival under the new LAS system appears to be similar to that in historic reports. However, risk of death was significantly increased among patients with LAS46.

Background Despite 40 years of heart transplantation, the optimal atrial anastomotic technique remains unclear. The United Network for Organ Sharing (UNOS) database provides a unique and novel opportunity to address this question by examining survival in a large cohort of patients undergoing orthotopic heart transplantation (OHT). We hypothesized that, when examining the issue on a large scale, no difference in survival would exist between techniques. Methods We retrospectively reviewed first-time adult OHT in the UNOS database to identify 14,418 patients undergoing OHT between the years 1999 and 2005. Primary stratification was between those who underwent bicaval vs biatrial techniques. Baseline demographic and clinical factors were also recorded. The primary end-point was mortality from all causes during the study period. Secondary outcomes included length of hospital stay (LOS), and need for permanent pacemaker placement (PP). Post-transplant survival was compared between groups using a Cox proportional hazard regression model. Results Of the 11,931 patients who met inclusion criteria between 1999 and 2005, 5,207 (44%) underwent the bicaval anastomotic technique. Bicaval and biatrial groups were well matched for gender, donor age, ischemic time, pulmonary vascular resistance, transpulmonary gradient, cardiac index, body mass index and pre-operative creatinine. Technique was not associated with survival during the study period (hazard ratio 1.06, p = 0.31). On multivariate analysis, age, gender, donor age and ischemic time were independent predictors of mortality. The bicaval technique was associated with less need for post-operative PP (2.0% vs 5.3%, p p Conclusions This study is the single largest series examining bicaval vs biatrial anastamotic techniques for OHT. We found no difference in survival between the two groups, although the bicaval technique was associated with shorter LOS and pacemaker placement. Both techniques lead to equivalent survival in OHT.