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Although the SynCardia total artificial heart (SynCardia Systems, LLC) was approved for use as a bridge to transplantation in 2004 in the United States, most centers do not adopt the total artificial heart as a standard bridging strategy for patients with biventricular failure. This study was designed to characterize the current use and outcomes of patients placed on total artificial heart support. The United Network of Organ Sharing Standard Transplant Research File was queried to identify total artificial heart implantation in the United States between 2005 and 2018. Multivariable Cox regression models were used for risk prediction. A total of 471 patients (mean age, 49 years; standard deviation, 13 years; 88% were male) underwent total artificial heart implantation. Of 161 transplant centers, 11 centers had cumulative volume of 10 or more implants. The 6-month cumulative incidence of mortality on the total artificial heart was 24.6%. The 6-month cumulative incidence of transplant was 49.0%. The 1-year mortality post-transplantation was 20.0%. Cumulative center volume less than 10 implants was predictive of both mortality on the total artificial heart (hazard ratio, 2.2, 95% confidence interval, 1.5-3.1, P <.001) and post-transplant mortality after a total artificial heart bridge (hazard ratio, 1.5, 95% confidence interval, 1.0-2.2, P =.039). Total artificial heart use is low, but the total artificial heart can be an option for biventricular bridge to transplant with acceptable bridge to transplant and post-transplant survival, especially in higher-volume centers. The observation of inferior outcomes in lower-volume centers raises questions as to whether targeted training, center certifications, and minimum volume requirements could improve outcomes for patients requiring the total artificial heart. [Display omitted] [ABSTRACT FROM AUTHOR]

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Objective Surgical therapy for refractory primary cardiogenic shock is largely based on emergent placement of extracorporeal membrane oxygenation or short-term ventricular assist devices. We have adopted a strategy of routine implantation of durable left ventricular assist devices (LVAD) as initial therapy for refractory cardiogenic shock, in patients who are potential candidates for heart transplantation, and report our experience. Methods Retrospective review of 43 consecutive patients with refractory shock caused by acute myocardial infarction (n = 21) or acute decompensated heart failure (n = 22) who were treated with primary implantation of a durable LVAD in a single institution. Results All patients received durable LVAD (axial flow, n = 37; centrifugal, n = 4; pulsatile, n = 2), with concurrent placement of right ventricular assist device (RVAD) in 5 patients (12%). One patient had delayed RVAD implantation. Mean operative time was 362 minutes and mean cardiopulmonary bypass time was 94 minutes. Twenty patients underwent concurrent cardiac procedures. Major early adverse events included operative mortality 14% (6/43), reoperation for bleeding 7% (3/43), and stroke 4.7% (2/43). Median time on mechanical ventilation was 3.5 days, ICU stay 9 days, and hospital stay 25 days. Kaplan-Meier survival was 82.7 ± 6.0% at 6 months and 73.9 ± 8.0% at 12 months. Using competing analysis, the cumulative incidence of transplantation was 10.3 ± 5.0% at 6 months and 30.8 ± 7.9% at 1 year. Conclusions Our data challenge the notion that patients in refractory cardiogenic shock are best served by an initial period of stabilization with temporary devices. Primary implantation of durable LVADs in cardiogenic shock can yield good midterm outcomes and may have potential benefits. [ABSTRACT FROM AUTHOR]

Continuous-flow left ventricular assist devices (LVADs) have revolutionized advanced heart failure care. These compact, fully implantable heart pumps are capable of providing meaningful increases in survival, functional capacity, and quality of life. Implantation volumes continue to grow, but several challenges remain to be overcome before LVADs will be considered as the therapy of choice for all patients with advanced heart failure. They must be able to consistently extend survival for the long term (7 to 10 years), rather than the midterm (3 to 5 years) more typical of contemporary devices; they must incorporate design elements that reduce shear stress and avoid stasis to reduce the frequent adverse events of bleeding, stroke, and pump thrombosis; and they must become more cost-effective. The advancements in engineering, implantation technique, and medical management detailed in this review will highlight the progress made toward achieving lifelong LVAD support and the challenges that remain. [ABSTRACT FROM AUTHOR]

This study aims to describe the outcomes after heart transplantation using a bridge-to-bridge strategy with a sequence of extracorporeal membrane oxygenation (ECMO) support followed by temporary total artificial heart implantation (TAH-t). A retrospective, multicenter analysis of 54 patients who underwent TAH-t implantation following an ECMO for cardiogenic shock was performed (ECMO-TAH-t group). A control group of 163 patients who underwent TAH-t implantation as a direct bridge to transplantation (TAH-t group) was used to assess this strategy's impact on outcomes. Fifty-four patients, averaging 47 ± 13 year old, underwent implantation of a TAH-t after 5.3 ± 3.4 days of ECMO perfusion for cardiogenic shock. In the ECMO-TAH-t group, 20 patients (20/54%; 37%) died after TAH-t implantation and 57 patients (57/163%; 35%) died in the TAH-t group (Gray test; P =.49). The top 3 causes of death of patients on TAH-t support were multisystem organ failure (40%), sepsis (20%), and neurologic events (20%). Overall, 32 patients (32/54%; 59%) underwent heart transplantation in the ECMO-TAH-t group compared with 106 patients (106/163%, 65%) in the TAH-t group (P =.44). No significant difference in survival was observed at 6 months, 1 year, and 3 years after heart transplant (ECMO-TAH-t group: 94%, 87%, and 80% vs 87%, 83%, and 76% in the TAH-t group, respectively). Deterioration of liver function (bilirubin, aspartate transaminase, and alanine aminotransferase levels on TAH-t) was associated with increased mortality before heart transplant in both groups. Sequential bridging from ECMO to TAH-t followed by heart transplantation is a viable option for a group of highly selected patients. [Display omitted] [ABSTRACT FROM AUTHOR]

Objective To develop a score to allow stratification of complexity in degenerative mitral valve repair. Methods Retrospective modeling of data from 668 consecutive patients who underwent surgery for mitral valve prolapse. A complexity scoring scale was developed using a consensus approach, assigning a score to each valve, based on the following: prolapsing segments (weight 1 for each posterior segment; weight 2 for each anterior or commissural segment); presence of valve restriction (weight 2); presence of calcification (weight 3 if annulus involved, otherwise weight 2); and prior mitral valve repair (weight 3). Valve repairs were categorized into 3 groups based on the complexity score: 1: Simple (n = 244); 2-4: Intermediate (n = 260); ≥5: Complex (n = 164). Results Mitral valve repair was successfully performed in 667 patients (repair rate: 99.9%). The complexity score was directly correlated with surrogates of technical complexity. The mean cardiopulmonary bypass time increased with lesion complexity ([in minutes] simple: 152; intermediate: 167; complex 195; P < .001). The median number of repair techniques utilized was related to lesion complexity (simple: 3; intermediate: 4; complex: 5; P < .001). Barlow's type etiology was more prevalent in complex cases (63%), compared with simple (9%) and intermediate (35%) cases ( P < .001). Advanced repair techniques were required to complete repair in 51% of complex cases, compared with 14% of intermediate and 0% of simple cases ( P < .001). Early and late outcomes were similar. Conclusions Our scoring system may allow effective stratification of complexity of mitral valve repair. Future studies are required to evaluate the use of our score in a prospective setting. [ABSTRACT FROM AUTHOR]

Alternative non-sternotomy approaches to implanting left ventricular assist devices have become viable and reproducible alternatives to standard sternotomy approach. This paper outlines the essential steps of the left subcostal- right-minithoracotomy approach for left ventricular assist device implantation. The left subcostal approach offers excellent access to the cardiac apex without disrupting the left chest wall, while the aorta can be easily accessed via a right mini-thoracotomy incision. [ABSTRACT FROM AUTHOR]

A 47-year-old woman with a mechanical mitral valve underwent a catheter-based atrial fibrillation ablation procedure, which was complicated by the dislodgment and immediate embolization of one of the valve leaflets. Acute severe mitral regurgitation and cardiogenic shock developed, necessitating emergency reoperative mitral valve re-replacement. She subsequently underwent a successful staged retrieval of the embolized leaflet from the abdominal aorta. [ABSTRACT FROM AUTHOR]

Over the past 3 decades, several observational studies established a role for surgical ventricular restoration (SVR) in the treatment of ischemic cardiomyopathy. In 2009, the Surgical Treatment for Ischemic Heart Failure (STICH) trial reported their findings and found no benefit of adding SVR to coronary artery bypass surgery in ischemic dilated cardiomyopathy. The STICH findings precipitated a decline in interest in SVR. In this article, we review the historical background and observational data that established a role for SVR. We critically review the STICH trial, and contend that the limitations are such that the study cannot provide any reliable conclusion on the role of SVR because of suboptimal patient selection and inadequacy of volume reduction (only 19% mean reduction in volume). Several post-STICH publications continue to demonstrate that SVR is effective in dilated ventricles, provided the procedure achieves >30% volume reduction. It is critical that surgeons continue their work in SVR, and continue to analyze their data, to enable better clarification of the indications and future role for this procedure. [Copyright &y& Elsevier]

Background: Although mitral valve repair is the recommended treatment for severe mitral regurgitation of degenerative etiology, valve replacement remains common, particularly for complex lesions or anterior leaflet involvement. We sought to characterize the feasibility and outcomes of an “all comers” repair strategy applied systematically in all cases of degenerative mitral valve disease, regardless of age, complexity, or leaflet involvement. Methods: From January 2002 to December 2010, 744 consecutive patients (mean age, 58 ± 13 years [range, 12-90]; mean LVEF, 55% ± 9%) with degenerative mitral valve regurgitation and prolapse (anterior leaflet: n = 42, 6%; posterior leaflet: n = 556, 75%; bileaflet: n = 146, 19%) underwent mitral valve surgery. Annular, leaflet or chordal calcification was present in 27% of cases. Results: All patients underwent mitral valve repair and received a concomitant annuloplasty with a median ring size of 32 mm (interquartile range, 30-36). There was 1 early valve replacement (99.9% repair rate) due to atrioventricular groove bleeding and 5 late re-repairs (0.7%) due to disease progression or infective endocarditis. In-hospital mortality and major stroke rates were 0.8% and 0.5%, respectively. Survival rates at 1 and 5 years were 99.2% ± 0.3% and 97.4% ± 0.8%, respectively. Seven-year freedom from reoperation was 97.1% ± 0.6%. The estimate of patients with <3+ mitral regurgitation at 4 and 7 years was 98% and 96%, respectively, and 95% and 91%, respectively, for <2+ mitral regurgitation. Conclusions: A systematic strategy of mitral valve repair that uses a variety of techniques allows repair of all degenerative valves in a reference center, with good short-term outcomes and mid-term durability. Further study is required to document the long-term efficacy of an “all comers” mitral valve repair strategy in degenerative subgroups with very complex valve morphology. [ABSTRACT FROM AUTHOR]

Background: Mycotic pseudoaneurysm is a rare but potentially lethal complication after heart transplantation. Allograft has been advocated as the choice of material for aortic replacement. We report a series of 7 patients with pseudoaneurysm that was treated with primary repair or synthetic graft replacement. Methods: Between October 2005 and February 2011, 8 patients (mean age, 55.3 years; range, 39 to 67 years), were diagnosed with mycotic pseudoaneurysms of the ascending aorta 2 to 29 months after transplantation. One patient declined operative repair, and the remainder had urgent or emergency surgical intervention. One patient had primary repair at the cardioplegia site, and one had primary end-to-end anastomosis after the infected recipient aortic segment was resected. Five patients had replacement of the infected aorta with a Dacron graft (DuPont, Wilmington, DE) for pseudoaneurysm development at the suture line or donor aorta. Clinical and radiologic follow-up assessments were performed in all patients. Results: There were no operative or in-hospital deaths. None of the patients had major postoperative complications, and there was no cardiac allograft dysfunction. Median follow-up was 25 months (range, 1 to 48 months). One patient died of a pulmonary embolism 10 months after the operation. The remaining 6 patients remain free of infection. The most recent radiologic follow-up showed no residual or recurrence of pseudoaneurysms among the surviving patients. Conclusions: A synthetic vascular graft to replace the infected aorta is a viable aortic substitute among transplant recipients, and in the presence of a vascularized flap, can offer excellent midterm outcomes. [Copyright &y& Elsevier]

The standard implantation of the Heartmate II left ventricular assist device (LVAD) (Thoratec Inc, Pleasanton, CA) involves a median sternotomy. There are some theoretical advantages to avoiding a median sternotomy in LVAD implantation. Hill et al introduced the concept of implantation of LVADs via a combination of right mini-thoracotomy and left subcostal incision and used this approach to implant the Thoratec paracorporeal LVAD (Thoratec Inc). Gregoric et al subsequently described a less invasive approach for implanting the Heartmate II LVAD without median sternotomy by using a subcostal incision and a right mini-thoracotomy, and they used the approach in 3 patients. With some modifications, we now use this method for routine implantation of the Heartmate II and describe our technique. [ABSTRACT FROM AUTHOR]

Background: Limited data exist regarding the epidemiology and prognosis of seizures in adults after cardiac surgery. The aim of this study was to define preoperative predictors of seizures and impact on postoperative outcomes. Methods: A prospective database of 2,578 consecutive adults who underwent cardiac surgery at a single institution between April 2007 and December 2009 was retrospectively analyzed to determine risk factors for postoperative seizures and prognostic impact. No patient received tranexamic acid or aprotinin. Results: Seizures occurred in 31 patients (1%) at a median of 2 days postoperatively (1 patient had a preoperative diagnosis of seizure disorder). Seizures were classified as generalized tonic-clonic (71%), simple/complex partial (26%), or status epilepticus (3%). Incidence differed according to procedure (coronary bypass 0.1%, isolated valve 1%, valve/coronary bypass 3%, aorta 5%; p <0.001). Patients who experienced seizures had nearly a fivefold higher operative mortality than patients who did not (29% versus 6%, p <0.001). Head computed tomography was performed in 26 patients (84%), of whom ischemic strokes were identified in 14 cases (53%). These were embolic in 9 patients (34%), and watershed in 3 (12%). Hemorrhagic strokes were observed in 2 patients (8%). The occurrence of a new postoperative stroke in seizure patients did not significantly increase the likelihood of in-hospital death. Thirteen patients (41%) were discharged without neurologic deficit. Multivariable logistic regression analysis identified three risk factors for seizure: deep hypothermic circulatory arrest, aortic calcification or atheroma, and critical preoperative state. Conclusions: Seizures in adults after cardiac surgery are strong independent predictors of permanent neurologic deficit and increased operative mortality. Early head computed tomography may be indicated to identify treatable pathology. [ABSTRACT FROM AUTHOR]

We describe preemptive placement of a TandemHeart percutaneous left ventricular assist device (CardiacAssist Inc, Pittsburgh, PA) through the axillary artery and vein for temporary postoperative support in a patient with severe left ventricular dysfunction undergoing high-risk cardiac reoperation. We believe this approach is preferable to high-dose catecholamines because of preserved early tissue perfusion without excessive vasoconstriction. Axillo-axillary placement is advantageous because patients can sit up and partially mobilize, and there is no need to reopen the chest for explantation. [Copyright &y& Elsevier]

We describe the case of a 58-year-old man who underwent coronary artery bypass grafting with an unremarkable transesophageal echocardiogram. Three years later he underwent a routine transthoracic echocardiogram that was normal. Eleven months later he presented with dyspnea and right-sided heart failure. Transthoracic echocardiogram showed a large mass located in the right atrium in which the base was inserted by the junction of the inferior vena cava and coronary sinus. Pathology showed a myxoma that measured 15 × 3 cm implying a growth rate of 1.36 × 0.3 cm/month. [Copyright &y& Elsevier]

The management of severe mitral regurgitation (MR) at the time of left ventricular assist device (LVAD) implantation is controversial. We adopted an approach of systematic repair of severe MR at the time of LVAD implantation and report our experience. We performed mitral valve repair (MVr) on 78 consecutive patients with severe MR undergoing LVAD implantation at our institution between 2013 and 2017. We compared data on these patients to 28 historical controls with severe MR from the immediate preceding period between 2011 and 2013 where the MR was not treated, using Cox modeling and propensity score methods. Median follow-up time was 17.7 months. Patients who underwent MVr were younger than those who did not (non-MVr group) (55 vs 63 years; P =.006), but otherwise had similar preoperative characteristics. The incidence of 30-day mortality (2.6% vs 3.6%; P =.78) and other early major adverse events was similar in both groups. At 3 months, no patient in the MVr group had more than mild MR compared with 7 patients (29%) in the non-MVr group (P <.001). Cardiac catheterization done 3 to 6 months after surgery showed tendency toward greater reduction from preoperative pulmonary artery systolic pressure in the MVr group compared with the non-MVr group (−20 vs −13 mm Hg; P =.10). The cumulative incidence of readmission due to congestive heart failure at 2 years was lower in the MVr group than in non-MVr group (7.1% vs 19.7%; adjusted hazard ratio, 0.18; 95% confidence interval, 0.04-0.76; P =.02). Concurrent MVr at the time of LVAD implantation can be done safely without increase in perioperative adverse events. MVr may be associated with better reduction in severity of MR and may have potential benefit in terms of reduction in readmissions for heart failure. [ABSTRACT FROM AUTHOR]

Background Consensus guidelines recommend repair over replacement for the surgical treatment of active native mitral valve infective endocarditis. However, contemporary practice and long-term outcome data are limited. Methods Multivariable Cox regression was used to compare outcomes of 1970 patients undergoing isolated primary mitral valve repair (n = 367, 19%) or replacement (n = 1603, 81%) for active infective endocarditis between 1998 and 2010 in New York and California states. The primary outcome was long-term survival. Secondary outcomes were recurrent endocarditis and mitral reoperation. Median follow-up time was 6.6 years (range 0-12), and last follow-up date was December 31, 2015. Results Mitral valve repair rates increased from 10.7% to 19.4% over the study period ( P < .001). Patients undergoing mitral repair were younger (55 ± 15 vs 57 ± 15 years, P = .005), less likely to have congestive heart failure (46.3% vs 57.1%, P < .001), and less likely to have staphylococcal infections (21.3% vs 32.0%, P < .001). Twelve-year survival was 68.8% (95% confidence interval [CI], 62.5%-74.3%) after mitral repair, versus 53.5% (95% CI, 50.6%-56.4%) after replacement (adjusted hazard ratio, 0.71; 95% CI, 0.57-0.88; P = .002). Mitral repair was associated with lower rate of recurrent endocarditis at 12 years than replacement (4.7% [95% CI, 2.8%-7.2%] vs 9.5% [95% CI, 8.0-11.1%]; P = .03), and similar rate of reoperation (9.1% [95% CI, 6.2%-12.8%] vs 8.6% [95% CI, 7.1%-10.4%]; P = .12). Conclusions In active endocarditis, mitral valve repair is associated with better survival and lower risk of recurrent infection compared with valve replacement and should be the surgery of choice when feasible. [ABSTRACT FROM AUTHOR]

Objective The preoperative ejection fraction (EF) and left ventricular (LV) end-systolic dimension are known predictors of postoperative LV dysfunction after mitral valve repair. We investigated the effect of a preoperative history of atrial fibrillation and moderate pulmonary hypertension (defined as pulmonary artery systolic pressure >50 mm Hg) on early postoperative LV dysfunction. Methods From 2003 to 2010, 632 patients who had undergone successful mitral valve repair surgery for degenerative disease were included in the present study. The preoperative and postoperative echocardiographic data and postoperative outcomes were collected retrospectively. We analyzed the demographic, hemodynamic, and echocardiographic parameters to assess the predictors of early postoperative LV dysfunction, defined as an LVEF <50%. Results The mean age of the cohort was 57 ± 13 years. All patients had less than mild mitral regurgitation on postoperative echocardiography. After mitral valve repair, a significant decrease in the LVEF (60% ± 8% to 54% ± 9%), LV end-systolic diameter (36 ± 7 mm to 33 ± 7 mm), and LV end-diastolic dimension (56 ± 8 mm to 48 ± 7 mm) was observed at early postoperative echocardiography (P < .001). On multivariate regression analysis, preoperative atrial fibrillation, pulmonary hypertension, and LV end-systolic dimension were independent predictors of the postoperative LVEF (P = .035 and P < .001, respectively). Preoperative atrial fibrillation (odds ratio, 1.97; 95% confidence interval, 1.28-3.02; P = .002) and pulmonary artery systolic pressure >50 mm Hg (odds ratio, 1.82; 95% confidence interval, 1.11-2.97; P = .017) increased the risk of postoperative LV dysfunction by almost twofold. Conclusions In addition to the established predictors of postoperative LV dysfunction, the presence of preoperative pulmonary hypertension and a history of atrial fibrillation in patients undergoing mitral valve repair surgery increased the risk of early postoperative LV dysfunction by almost twofold. [ABSTRACT FROM AUTHOR]

Controversy exists regarding the indication and method of repair of functional tricuspid regurgitation (TR) in patients undergoing mitral valve surgery. Whereas the American College of Cardiology/American Heart Association guidelines recommend tricuspid repair in the setting of severe TR, tricuspid repair is advised for less than severe TR in the setting of annular dilation or pulmonary hypertension. Although multiple repair strategies exist, the use of a ring annuloplasty (semirigid remodeling rings vs flexible bands) is the preferred method of therapy to avoid short- and long-term recurrence of TR. The new Tri-Ad Adams annuloplasty ring combines elements of semirigid and flexible bands that will not only allow for annular remodeling in the region of the right ventricular free wall but also potentially reduce injury to the conduction system with its flexible and “open” ends. In this article, we discuss the rational for an aggressive approach to functional tricuspid regurgitation, and show our initial clinical experience with the Tri-Ad Adams annuloplasty ring. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the effectiveness and outcomes of an intraoperative and postoperative algorithm for managing systolic anterior motion (SAM) after mitral valve repair (MVRr). Methods: All consecutive patients who underwent MVRr for degenerative disease from January 2002 to June 2011 were included, with the data collected retrospectively. Patients who underwent MVRr for primary SAM were excluded from the study. Patients who developed SAM after the repair were systematically treated according to the algorithm. The intraoperative algorithm first involved medical management techniques, followed by surgical correction for significant SAM (mild or greater mitral regurgitation, left ventricular outflow tract gradient > 50 mm Hg). The postoperative algorithm focused on medical management and symptoms to guide the treatment decisions. Results: The overall in-hospital incidence of SAM was 6.6% (52/785). In 41 patients, SAM was identified in the operating room, and in 11 patients, it was found postoperatively on the predischarge echocardiogram. Of the 41 patients with intraoperative SAM, 35 (85.4%) had resolution with medical management and 6 (14.6%) required surgical repeat repair while in the operating room. No patient required mitral valve replacement for persistent SAM. Postoperatively, 11 new cases were identified, and 7 cases of resolved intraoperative SAM recurred. These postoperative cases of SAM were managed according to the postoperative SAM algorithm. At last follow-up, 17 (94.4%) of 18 patients had resolution of SAM and 1 (5.6%) patient had mild SAM (less than mild mitral regurgitation, peak left ventricular outflow tract gradient < 50 mm Hg) and were asymptomatic. No patients with postoperative SAM required reoperation after their initial surgery. The median echocardiographic follow-up was 1.3 years. During follow-up, 1 early death (noncardiac) and 2 late deaths (1 noncardiac, 1 of unknown etiology) occurred. Conclusions: SAM is a relatively frequent complication after MVRr and can occur intraoperatively or postoperatively. A systematic approach addressing perioperative SAM after MVRr yields excellent mid-term results. [ABSTRACT FROM AUTHOR]

Giant left atrium in a patient who requires heart transplantation not only poses a significant mortality risk due to compression effect on the surrounding intrathoracic structures but also leads to technical difficulties during transplantation, especially with the left atrial anastomosis. We discuss a case of a patient with a giant left atrium with end-stage valvular cardiomyopathy where simultaneous ventricular assist device placement and left atrium reduction plasty was undertaken as a bridge to cardiac transplantation. [Copyright &y& Elsevier]

Simultaneous heart-kidney transplantation has been increasingly performed in end-stage heart failure patients with concurrent kidney dysfunction despite limited evidence supporting its indications and utility. The purpose of this study was to investigate the effects and utility of simultaneously implanted kidney allografts with various degrees of kidney dysfunction during heart transplantation. Using the United Network for Organ Sharing registry, long-term mortality was compared in recipients with kidney dysfunction who underwent heart-kidney transplantation (n = 1,124) vs isolated heart transplantation (n = 12,415) in the United States between 2005 and 2018. In heart-kidney recipients, contralateral kidney recipients were compared for allograft loss. Multivariable Cox regression was used for risk adjustment. Long-term mortality was lower among heart-kidney recipients than among heart-alone recipients when recipients were on dialysis (26.7% vs 38.6% at 5 years; HR: 0.72; 95% CI: 0.58-0.89) or had a glomerular filtration rate (GFR) of <30 mL/min/1.73 m2 (19.3% vs 32.4%; HR: 0.62; 95% CI: 0.46-0.82) and GFR of 30 to 45 mL/min/1.73 m2 (16.2% vs 24.3%; HR: 0.68; 95% CI: 0.48-0.97) but not in GFR of 45 to 60 mL/min/1.73 m2. Interaction analysis showed that the mortality benefit of heart-kidney transplantation continued up to GFR 40 mL/min/1.73 m2. The incidence of kidney allograft loss was higher among heart-kidney recipients than among contralateral kidney recipients (14.7% vs 4.5% at 1 year; HR: 1.7; 95% CI: 1.4-2.1). Heart-kidney transplantation relative to heart transplantation alone provided superior survival for dialysis-dependent recipients and non–dialysis-dependent recipients up to a GFR of approximately 40 mL/min/1.73 m2 but at the cost of almost twice the risk of kidney allograft loss than contralateral kidney allograft recipients. [Display omitted] [ABSTRACT FROM AUTHOR]