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Background: Prolonged hospital length of stay (PLOS) after heart transplantation increases cost and morbidity. To better inform care, we developed a risk score to identify patients at risk for PLOS after heart transplantation., Methods: We queried the United Network for Organ Sharing Scientific Registry of Transplant Recipients database for adult patients who underwent isolated heart transplantation from 2003 to 2012. The population was randomly divided into a derivation cohort (80%) and a validation cohort (20%). The outcome of interest was PLOS, defined as a posttransplant hospital length of stay of more than 30 days. Associated univariables (p < 0.20) in the derivation cohort were included in a multivariable model, and a risk index was derived from the adjusted odds ratios of significant covariates., Results: During the study period, 16,723 patients underwent heart transplantation with an average PLOS of 19 ± 21 days, and 2,020 orthotopic heart transplant recipients (12%) had PLOS. Baseline characteristics were similar between the derivation and validation cohorts. Twenty-four recipient and nine donor variables, cold ischemic time, and center volume were tested as univariables. Seventeen covariates significantly affected PLOS and comprised the prolonged hospitalization after heart transplant risk score, which was stratified into three risk groups. The risk model was subsequently validated, and predicted rates of PLOS correlated well with observed rates (R = 0.79). Rates of PLOS in the validation cohort were 8.3%, 11%, and 22% for low, moderate, and high risk groups, respectively., Conclusions: The risk of PLOS after heart transplantation can be determined at the time of transplant. The prolonged hospitalization after heart transplant score may lead to individualized postoperative management strategies to reduce duration of hospitalization for patients at high risk., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Concerns over prolonged allograft ischemia have limited the widespread adoption of long-distance organ procurement in heart transplantation (HT). We sought to assess whether donor distance from the center of transplantation independently affects mortality., Methods: We queried the United Network for Organ Sharing (UNOS) database for adults undergoing isolated HT from 2005 to 2012. Risk-adjusted Cox proportional hazards models were constructed for the primary outcomes of 30-day and 1-year mortality, and the independent impact of donor distance from transplantation center at the time of procurement was assessed., Results: We included 14,588 heart transplant recipients. The mean distance from location of the donor heart to transplantation center was 184.4 ± 214.6 miles; 1,214 HTs (8.3%) occurred at the same location as the donor heart. Ischemic times were inversely related to the distance from the site of donor procurement to recipient transplantation. After risk adjustment, longer donor distances (in miles) were associated with a significantly lower risk of mortality at both 30 days (hazard ratio [HR] 0.9993, 95% confidence interval [CI]: 0.9988 to 0.9998, p < 0.01) and 1 year (HR 0.9994, 95% CI: 0.9989 to 0.9999, p = 0.015). Risk-adjusted hazards for mortality were significantly reduced in recipients receiving hearts from more than 25 miles away. The hazard reduction was greatest in recipients receiving donor hearts from more than 500 miles away (1-year HR 0.64, p < 0.01; 30-day HR 0.47, p < 0.01)., Conclusions: Longer distances between donor location and center of heart transplantation are associated with a reduced hazard for survival at 30 days and 1 year, despite greater ischemic times. Future studies are necessary to elucidate the protective factors surrounding long-distance heart donation., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: This study evaluated the effect of simultaneous heart-kidney transplantation (SHK) on survival stratified by preoperative renal function., Methods: Patients undergoing SHK or heart transplant alone (HTA) between 1992 and 2012 were identified in the United Network for Organ Sharing database. Patients were primarily stratified by the need for dialysis before transplantation. Nondialysis patients were further stratified by preoperative glomerular filtration rate (GFR) and likelihood of postoperative development of renal failure requiring new-onset dialysis (high risk defined as ≥75th percentile according to a previously derived and validated risk score). The primary outcome was 5-year survival, evaluated by Kaplan-Meier and multivariable logistic regression analyses., Results: Included were 665 (2%) SHK and 38,488 (98%) HTA patients. SHK improved 5-year survival in dialysis-dependent patients (69% vs 54%, p < 0.001), with no survival difference in patients with a preoperative GFR ≥60 mL/min/1.73 m(2) (84% SHK vs 77% HTA, p = 0.34). In patients with a preoperative GFR of less than 60 mL/min/1.73 m(2), being high risk for postoperative new-onset dialysis discriminated those patients who would benefit from SHK (5-year survival low risk: 82% SHK vs 76% HTA, p = 0.27; 5-year survival high risk: 86% SHK vs 67% HTA, p < 0.001). Risk-adjusted analysis confirmed these findings. SHK comprised only 2.6% of heart transplants in patients with a preoperative GFR of less than 60 mL/min/1.73 m(2) who were at high risk for postoperative renal failure., Conclusions: SHK improves long-term survival not only in dialysis-dependent patients but also in patients with reduced preoperative GFR who are at high risk for postoperative new-onset dialysis. Expansion of SHK into this subset warrants further study, especially considering its low current utilization., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: This study derived and validated a risk index for postoperative renal failure after orthotopic heart transplantation., Methods: Adult orthotopic heart transplantations performed between 2000 and 2010 were identified in the United Network for Organ Sharing database. Patients were randomly divided 4:1 into derivation and validation cohorts. The primary outcome was new-onset postoperative renal failure requiring dialysis. A multivariable model was created incorporating variables associated with renal failure in univariate analysis, with significant risk factors assigned points based on odds ratios. A simple guide was generated to demonstrate ranges of risk scores associated with clinically meaningful renal failure rates., Results: A total of 14,635 orthotopic heart transplantation recipients were included. New-onset postoperative renal failure occurred in 1128 patients (7.7%). A 100-point risk score was generated using 13 significant risk factors. There was a high degree of correlation between actual renal failure rates in the validation cohort and predicted rates in the derivation cohort based on risk scores (r = 0.91, P < .001). Renal failure risk categories were generated on the basis of probabilities determined in the derivation cohort: low (<5% risk, score 0-15), average (5%-10% risk, score 16-26), above average (10%-20% risk, score 27-39), and high (>20% risk, score ≥ 40). The actual renal failure rates in the validation cohort for these risk score ranges corresponded to the risk category they were assigned to: score 0 to 15 (4.1% rate), score 16 to 26 (6.8% rate), score 27 to 39 (13.2% rate), and score 40 or more (20.2% rate)., Conclusions: This 100-point risk index incorporating 13 risk factors is highly predictive of new-onset postoperative renal failure after orthotopic heart transplantation. Prospective assessment of orthotopic heart transplant recipients using the risk categories that were generated on the basis of score ranges may help in tailoring perioperative management., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: This study evaluated changes in physical functional performance after orthotopic heart transplantation (OHT) with particular attention to the impact of recipient age on functional outcomes., Methods: Retrospective review of all first-time, single-organ adult OHTs in the United States between 2005 and 2010. Patients were primarily stratified by age. The validated Karnofsky performance scale, which ranges from 0 (death) to 100 (fully independent with no evidence of disease and no complaints), was used to measure functional status., Results: A total of 10,049 OHT recipients were identified, with 1,431 (14%) aged 65 years or greater. Mean Karnofsky score prior to OHT was comparable between cohorts (younger: 50.7±25.2 versus older: 50.1±25.0; p=0.38). At a median follow-up of 2.1 years (interquartile range 0.7 to 3.3 years), 64% of OHT recipients had improved functional performance. The mean improvement in Karnofsky score was similar between younger and older patients (19.6±42.0 vs 17.5±41.8; p=0.10). Twenty percent of younger patients were functionally independent prior to OHT, with 67% being functionally independent at last follow-up (p<0.001). Similarly, in the older cohort, 20% were functionally independent prior to OHT, with 66% being functionally independent at last follow-up (p<0.001). Multivariable analysis adjusting for potential confounders confirmed that age, both as a continuous and categoric variable, did not impact odds of functional improvement after OHT. Subanalysis using 70 years as the age cutoff produced similar results., Conclusions: In the modern era, OHT is associated with improvements in functional performance in most recipients, and this beneficial effect is preserved across the age spectrum. These data provide a benchmark for functional outcomes after OHT and may have important implications in organ allocation., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Although orthotopic heart transplantation (OHT) is increasingly being offered to older patients, few studies have evaluated outcomes in patients older than 70 years of age. We undertook this study to characterize the outcomes of septuagenarians bridged to transplantation (BTT) in the modern era., Methods: We conducted a retrospective cohort study of all adult OHT in the United Network for Organ Sharing database from 2005 to 2011. Primary stratification was by age 70 years or older. Subgroup analysis evaluated patients who received BTT. The primary outcome was survival as determined by the Kaplan-Meier method., Results: From January 2005 to December 2011, 12,274 adults underwent OHT, including 3,243 (26.4%) who received BTT. In the entire cohort, 11,996 (97.7%) recipients were aged 18 to 70 years, and 277 (2.3%) were 70 years of age or older. Overall, patients 70 years or older who underwent OHT had decreased 90-day survival (93.6% versus 88.8%; p<0.01), 1-year survival (89.0% versus 81.6%; p<0.01), and 2-year survival (85.4% versus 79.9%; p<0.01) compared with recipients of other ages. However in the BTT subgroup, recipients 70 years and older (n=43) had similar 90-day (91.2% versus 84.7%; p=0.2), 1-year (86.1% versus 81.7%; p=0.4), and 2-year (82.8% versus 81.7%; p=0.6) survival compared with recipients of other ages (n=3,200). After adjusting for multiple recipient and donor factors, age greater than or equal to 70 years was still not associated with an increased hazard of mortality at 90 days, 1 year, or 2 years. These results were verified by analysis of a propensity-matched cohort., Conclusions: Although patients older than the age of 70 years undergoing OHT have decreased survival, among patients who received BTT, septuagenarians have outcomes similar to those of younger recipients. In carefully selected patients dependent on left ventricular assist devices (LVADs), recipient age greater than or equal to 70 years should not be viewed as a contraindication to OHT., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Pre-transplant malignancy (PTM) is a relative contraindication to organ transplantation. Studies examining the effect of PTM on outcomes after lung transplantation (LTx) or orthotopic heart transplantation (OHT) are limited. We evaluated the effect of PTM on outcomes after LTx and OHT., Methods: We retrospectively reviewed primary adult LTx and OHT recipients in the United Network for Organ Sharing database. Primary stratification was by PTM and secondary stratification by tumor type. Matched cohorts (2:1) and multivariable Cox proportional hazards regression models were used to evaluate mortality., Results: From 2000 to 2011, 13,613 adults underwent LTx and 19,817 underwent OHT. PTM was present in 740 LTx patients (5.4%) and in 1,117 OHT patients (5.6%). On unadjusted analysis, LTx patients and OHT patients with PTM had similar 30-day, 1-year, and 5-year survivals (p<0.05) compared with patients with no PTM. These findings persisted after risk-adjustment . No tumor types were associated with increased mortality in LTx patients. OHT patients with leukemia, lymphoma, or myeloma (LLM) had a significant increase in univariate mortality at 30 days (hazard ratio [HR], 1.82; p = 0.04), 1 year (HR, 1.93; p<0.001), and 5 years (HR, 1.54; p = 0.01). Matched cohort analysis revealed comparable outcomes in LTx patients but confirmed increased univariate 1-year mortality (HR, 1.89; p = 0.006) in OHT patients with LLM., Conclusions: This large study evaluating the effects of PTM found the incidence of PTM was in LTx 5.4% and in OHT 5.6%. In general, PTM does not increase mortality in either cohort; however, OHT patients with LLM have an increased hazard of mortality. Therefore, carefully selected patients with PTM should not be excluded from LTx or OHT., (Copyright © 2013 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Background: Although left ventricular assist devices (LVADs) are now commonly used as a bridge to orthotopic heart transplantation (OHT), the upper patient age limit for this therapy has not been defined. Smaller studies have suggested that advanced age should not be a contraindication to bridge to transplantation (BTT) LVAD placement. The purpose of this study was to examine outcomes in patients 60 years and older undergoing BTT with continuous-flow LVADs., Methods: The United Network for Organ Sharing (UNOS) database was reviewed to identify first-time OHT recipients 60 years of age and older (2005-2010). Patients were stratified by preoperative support: continuous-flow LVAD, intravenous inotropic agents, and direct transplantation. Survival after OHT was modeled using the Kaplan-Meier method. All-cause mortality was examined using multivariable Cox proportional hazard regression., Results: Of 2,554 patients, 1,142 (44.7%) underwent direct transplantation, 264 (10.3%) had LVAD BTT, and 1,148 (45.0%) had BTT with inotropic agents. The mean age was 64±3 years, and 460 (18.0%) patients were women. Mean follow-up was 29±19 months. Survival differed significantly among the 3 groups. Patients with LVAD BTT had significantly lower survival after OHT compared with the other groups at 30 days and 1 year. This survival difference was no longer significant at 2 years after OHT or when deaths in the first 30 days were censored. LVAD BTT increased the hazard of death at 1 year by 50% (hazard ratio [HR], 1.50; 95% confidence interval [CI], 1.05-2.15; p=0.03), compared with patients who underwent direct transplantation., Conclusions: This study represents the largest modern cohort in which survival after OHT has been evaluated in patients 60 years or older who received BTT. Older patients have lower short-term survival after OHT when BTT is carried out with a continuous-flow LVAD compared with inotropic agents or direct transplantation., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Although several studies have examined factors affecting survival after orthotopic heart transplantation (OHT), few have evaluated the impact of reoperative sternotomy. We undertook this study to examine the incidence and impact of repeat sternotomies on OHT outcomes., Methods: We conducted a retrospective review of all adult OHT from 2 institutions. Primary stratification was by the number of prior sternotomies. The primary outcome was survival. Secondary outcomes included blood product utilization and commonly encountered postoperative complications. Multivariable Cox proportional hazards regression models examined mortality while linear regression models examined blood utilization., Results: From January 1995 to October 2011, 631 OHT were performed. Of these, 25 (4.0%) were redo OHT and 182 (28.8%) were bridged to transplant with a ventricular assist device; 356 (56.4%) had undergone at least 1 prior sternotomy. On unadjusted analysis, reoperative sternotomy was associated with decreased 90-day (98.5% vs 90.2%, p<0.001), 1-year (93.1% vs 79.6%, p<0.001), and 5-year (80.4% vs 70.1%, p=0.002) survival. This difference persisted on multivariable analysis at 90 days (hazard ratio [HR] 2.99, p=0.01), 1 year (HR 2.98, p=0.002), and 5 years (HR 1.62, p=0.049). The impact of an increasing number of prior sternotomies was negligible. On multivariable analysis, an increasing number of prior sternotomies was associated with increased intraoperative blood product utilization. Increasing blood utilization was associated with decreased 90-day, 1-year, and 5-year survival., Conclusions: Reoperative sternotomy is associated with increased mortality and blood utilization after OHT. Patients with more than 1 prior sternotomy do not experience additional increased mortality. Carefully selected patients with multiple prior sternotomies have decreased but acceptable outcomes., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the contribution of institutional volume and other unmeasured institutional factors beyond volume to the between-center variability in outcomes after orthotopic heart transplantation (OHT)., Background: It is unclear if institutional factors beyond volume have a significant impact on OHT outcomes., Methods: The United Network for Organ Sharing registry was used to identify OHTs performed between 2000 and 2010. Separate mixed-effect logistic regression models were constructed, with the primary endpoint being post-OHT mortality. Model A included only individual centers, model B added validated recipient and donor risk indices as well as the year of transplantation, and model C added institutional volume as a continuous variable to model B. The reduction in between-center variability in mortality between models B and C was used to define the contribution of institutional volume. Kaplan-Meier survival curves were also compared after stratifying patients into equal-size tertiles based on center volume., Results: A total of 119 centers performed OHT in 19,156 patients. After adjusting for transplantation year and differences in recipient and donor risk, decreasing center volume was associated with an increased risk of 1-year mortality (P < 0.001). However, procedural volume only accounted for 16.7% of the variability in mortality between centers, and significant between-center variability persisted after adjusting for institutional volume (P<0.001). In Kaplan-Meier analysis, there was significant variability in 1-year survival between centers within each volume category: low-volume (66.7%-96.6%), intermediate-volume (80.7%-97.3%), and high-volume (83.8%-93.9%). These trends were also observed with 5-year mortality., Conclusions: This large-cohort analysis demonstrates that although institutional volume is a significant predictor of post-OHT outcomes, there are other unmeasured institutional factors that contribute substantially to the between-center variability in outcomes. Institutional volume should therefore not be the sole indicator of "center quality" in OHT.

Background: This study examined whether institutional volume impacts outcomes after orthotopic heart transplantation (OHT) utilizing marginal donors., Methods: Adult patients undergoing OHT with the use of marginal donors between 2000 and 2010 were identified in the United Network for Organ Sharing database. A previously derived and validated donor risk score (range, 1 to 15) was used to define marginal donors as those in the 90th percentile of risk (score≥7). Patients were stratified into equal-size tertiles based on overall institutional OHT volume. Posttransplant outcomes were compared between these center cohorts., Results: A total of 3,176 OHTs utilizing marginal donors were identified. In Cox regression analysis, recipients undergoing OHT at low-volume centers were at significantly increased risk of 30-day (hazard ratio 1.82 [1.31 to 2.54], p<0.001), 1-year (hazard ratio 1.40 [1.14 to 1.73], p=0.002), and 5-year posttransplant mortality (hazard ratio 1.29 [1.10 to 1.52], p=0.02). These findings persisted after adjusting for recipient risk, differences in donor risk score, and year of transplantation (each p<0.05). In Kaplan-Meier analysis, there was a similar trend of decreasing 1-year survival with decreasing center volume: high (86.0%), intermediate (85.7%), and low (81.2%; log rank p=0.003). Drug-treated rejection within the first post-OHT year was more common in low-volume versus high-volume centers (34.3% versus 24.2%, p<0.001). At an overall mean follow-up of 3.4±2.9 years, low-volume centers also had higher incidences of death due to malignancy (2.8% versus 1.3%, p=0.01) or infection (6.2% versus 4.1%, p=0.02)., Conclusions: Consolidating the use of marginal donors to higher volume centers may be prudent in improving post-OHT outcomes in this higher risk patient subset., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The aim of this study was to derive and validate a risk score for rejection after orthotopic heart transplantation., Methods and Results: The United Network for Organ Sharing registry was used to identify patients undergoing orthotopic heart transplantation between 1998 and 2008. A total of 14 265 eligible patients were randomly divided into derivation (80%; n=11 412) and validation (20%; n=2853) cohorts. The primary outcome was drug-treated rejection within 1 year of orthotopic heart transplantation. Covariates found to be associated (exploratory univariate P<0.2) with rejection were entered into a multivariable logistic regression model. Inclusion of each variable in the model was assessed by improvement in the McFadden pseudo-R(2), likelihood ratio test, and c index. A risk score was then generated through the use of relative magnitudes of the odds ratios from the derivation cohort, and its ability to predict rejection was tested independently in the validation cohort. A 13-point risk score incorporating 4 variables (age, race, sex, HLA matching) was created. The mean scores in the derivation and validation cohorts were 8.3±2.2 and 8.4±2.1, respectively. Predicted 1-year rejection rates based on the derivation cohort ranged from 16.2% (score=0) to 50.7% (score=13; P<0.001). In weighted regression analysis, there was a strong correlation between these predicted rates of rejection and actual, observed rejection rates in the validation cohort (r(2)=0.96, P<0.001). Logistic regression analysis also demonstrated a significant association (odds ratio, 1.13; P<0.001). The c index of the composite score was equivalent in both the derivation and validation cohorts (c=0.67)., Conclusions: This novel 13-point risk score is highly predictive of clinically significant rejection episodes within 1 year of orthotopic heart transplantation. It has potential utility in tailoring immunosuppressive regimens and in research stratification in orthotopic heart transplantation.

Background: Recent evidence suggests patients bridged to heart transplant (BTT) have equivalent outcomes as those undergoing conventional orthotopic heart transplantation (OHT). However, data on risk factors for early death in BTT patients are limited., Methods: We retrospectively reviewed the United Network for Organ Sharing database of all patients bridged to OHT with a HeartMate II from January 2005 to December 2010. The primary outcome was all-cause 90-day mortality. Additional postoperative outcomes were cerebrovascular accident and need for renal replacement therapy. Kaplan-Meier analysis assessed survival. Preoperative variables associated with 90-day death on univariate analysis (p<0.2) were included in a multivariable Cox proportional hazards regression., Results: A HeartMate II was used to bridge 1,312 patients (average age, 52±12 years) to OHT, most commonly for idiopathic cardiomyopathy (50.7%). During the study, 171 patients (13.0%) died. The unadjusted 90-day survival was 92.3%. The highest annual average center volume in this cohort, examining for BTT recipients only, was 28 BTT procedures yearly. Postoperative cerebrovascular accident occurred in 29 patients (2.2%), and 106 (8.3%) required renal replacement therapy. Cox regression revealed age, glomerular filtration rate, African American race, human leukocyte antigen mismatch, serum bilirubin, need for mechanical ventilation, donor age, and prolonged ischemia time were associated with 90-day death. Early survival was improved for patients who underwent OHT at high-volume centers (p=0.01)., Conclusions: This study examining risk factors for early death in patients bridged to OHT using HeartMate II mechanical assistance will aid in identifying patients best suited to benefit from this technology., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2012 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Background: The aim of this study was to evaluate the impact of metabolic risk factors on mortality rates after orthotopic heart transplantation (OHT)., Methods: Adult patients undergoing OHT between 1998 and 2008 were identified in the United Network for Organ Sharing registry. The impact of metabolic risk factors (hypertension, diabetes mellitus, and obesity) on mortality post-OHT was evaluated in a Cox proportional hazards regression analysis adjusted for other variables associated with survival in univariate analysis (exploratory p value<0.2). Kaplan-Meier survival estimates were compared with the log-rank test., Results: A total of 15,960 eligible patients underwent OHT during the study period. There were 6,368 (39.9%) patients with none of these risk factors, 6,138 (38.5%) with 1 risk factor, 2,811 (17.6%) with 2 risk factors, and 643 (4.0%) who had all 3 risk factors. After adjusting for other significant variables influencing survival, each individual risk factor independently increased the likelihood of mortality post-OHT (hypertension: HR 1.10 [1.03 to 1.17]; diabetes: HR 1.22[1.13 to 1.31]; obesity: HR 1.17 [1.10 to 1.26], each p<0.01). There was an exponential trend of increasing mortality with the addition of each risk factor (r2=0.99, p<0.001) such that patients with all 3 risk factors had a 63% increased mortality compared with those with no risk factors (HR 1.63 [1.42 to 1.88], p<0.001). There was also a significant trend in declining 5-year survival rates with an increasing number of risk factors: 0 (74.7%), 1 (71.3%), 2 (68.2%), and 3 (63.1%) (p<0.001)., Conclusions: This large-cohort study demonstrates that an increasing number of metabolic risk factors in OHT recipients is associated with exponential increases in postoperative mortality rates., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The aim of this study was to identify recipient factors that are associated with a high risk of graft failure after heart retransplantation (HRT)., Methods: The prospectively collected United Network for Organ Sharing registry was used to identify patients undergoing HRT among 24,477 patients who had undergone cardiac transplantation between 1997 and 2009. The primary outcome was graft failure within 1 year of HRT. The impact of 35 recipient variables on the primary outcome was tested in exploratory univariate logistic regression analysis. Those factors found to be significantly associated with graft failure were entered into a multivariable logistic regression model., Results: A total of 671 patients underwent HRT during the study period. Overall, 302 (45%) grafts failed after HRT at a mean follow-up of 4.3±3.7 years. Three recipient factors were found to be associated with 1-year graft failure in the multivariate model: older age, increasing serum creatinine, and mechanical ventilation before HRT. Moreover, each decade increase in recipient age was associated with a 20% increase in odds of 1-year graft failure (odds ratio, 1.02; 95% confidence interval, 1.01 to 1.04; p=0.005). Similarly, each 1-mg/dL increase in serum creatinine increased odds of graft failure by 58% (odds ratio, 1.58; 95% confidence interval, 1.27 to 1.97; p<0.001). Patients who were mechanically ventilated had a fourfold higher likelihood of 1-year graft failure (odds ratio, 4.32; 95% confidence interval, 2.28 to 8.18; p<0.001)., Conclusions: The risk of graft failure after HRT increases with an increasing number of significant recipient risk factors, namely older age, increasing serum creatinine, and mechanical ventilation. These risk factors should serve as relative contraindications to HRT, especially when present in combination, given the higher rate of graft failure in these patients., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: This case-control study was conducted to identify factors predictive of 10-year survival after orthotopic heart transplantation (OHT)., Methods: Prospectively collected data from the United Network for Organ Sharing registry were reviewed to identify adult patients undergoing OHT between 1987 and 1999 (N=22,385) who had survived 10 years. Controls were those who had died within 10 years of OHT. Factors associated with 10-year survival were identified with multivariate logistic regression analysis. Lowess smoothing plots were used to identify linear breakpoints in continuous variables, and splines were incorporated when appropriate., Results: There were 9,404 ten-year survivors (42%; mean follow-up, 14.0±3.0 years) and 10,373 controls (46%) with a mean survival of 3.7±3.3 years post-OHT. Predictors of 10-year survival in the optimal multivariate model were age younger than 55 (odds ratio [OR], 1.24; 95% confidence interval [CI], 1.10 to 1.38; p<0.001), white race (OR, 1.35; 95% CI, 1.17 to 1.56; p<0.001), shorter ischemic time (OR, 1.11; 95% CI, 1.05 to 1.18; p<0.001), younger donor age (OR, 1.01; 95% CI, 1.01 to 1.02; p<0.001), annual center volume of 9 or more (OR, 1.31; 95% CI, 1.17 to 1.47; p<0.001), mechanical ventilation (OR, 0.53; 95% CI, 0.36 to 0.78; p=0.001), and diabetes (OR, 0.67; 95% CI, 0.57 to 0.78; p<0.001)., Conclusions: Age younger than 55 years, annual center volume of 9 or more, white race, shorter ischemic time, and younger donor age improved the likelihood of 10-year survival after OHT. Mechanical ventilation and diabetes reduced this likelihood. These data should serve as a useful guide to long-term prognostication in adult OHT., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: No standard index based on donor factors exists for predicting mortality after orthotopic heart transplantation (OHT). We utilized United Network for Organ Sharing (UNOS) data to develop a quantitative donor risk score for OHT., Methods: We examined a prospectively collected open cohort of 22,252 patients who underwent primary OHT (1996 to 2007). Of the 284 donor-specific variables, those associated with 1-year (year) mortality (exploratory p-value < 0.2) were incorporated into a multivariate (MV) logistic regression model. The final model contained donor factors that improved the explanatory power (by pseudo-R2, area under the curve and likelihood ratio test). A quantitative donor risk score was created using odds ratios (ORs) from the final model. For external validity, a cross-validation strategy was employed whereby the score was generated using a randomly generated subset of cases (n = 17,788) and then independently validated on the remaining patients (n = 4,464)., Results: A 15-point scoring system incorporated 4 variables: ischemic time; donor age; race mismatching; and blood urea nitrogen (BUN)/creatinine ratio. Derivation and validation cohort scores ranged from 1 to 15 and 1 to 12, respectively (mean 4.0 ± 2.1 for each). Each increase of 1 point increased the risk of 1-year death by 9% (OR = 0.09 [1.07 to 0.12]) in the derivation cohort and 13% (OR = 0.13 [1.08 to 0.18]) in the validation cohort (each p < 0.001). The odds of 1-year mortality by increments of 3 points were: 0 to 2 points (reference); 3 to 5 points (OR = 0.25 [1.12 to 0.40], p < 0.001); 6 to 8 pts (OR = 0.77 [1.56 to 2.02], p < 0.001); and 9 to 15 points (OR = 1.92 [1.54 to 2.39], p < 0.001). Donor risk score was predictive for 30-day mortality (OR = 0.11 [1.08 to 0.14], p < 0.001) and 5-year cumulative mortality (OR = 0.11 [1.09 to 0.13], p < 0.001)., Conclusions: We present a novel donor risk index for OHT predicting short- and long-term mortality. This donor risk score may prove valuable for donor heart allocation and prognosis after OHT., (Copyright © 2012 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Objectives: The aim of the present study was to identify the predictors of 5-year survival in elderly patients undergoing orthotopic heart transplantation (OHT)., Methods: A review of the United Network for Organ Sharing database was conducted of recipients 60 years old or older undergoing OHT from 1995 to 2004. The variables were compared between the 5-year survivors and the patients who died within 5 years of OHT. A multivariate logistic regression model was constructed using the covariates significantly associated with 5-year survival on univariate analysis., Results: A total of 5330 elderly patients underwent OHT during the study period. Of these patients, 3492 (65.5%) were 5-year survivors, 1580 (29.6%) had died within 5 years of OHT and were considered controls, and 258 (4.8%) were lost to follow-up. The predictors of improved 5-year survival included younger age (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.95-1.00; P = .03), lower creatinine (OR, 0.92; 95% CI, 0.87-0.98; P = .01), white race (OR, 1.23; 95% CI, 1.02-1.49; P = .03), shorter ischemic time (OR, 0.93; 95% CI, 0.87-0.99; P = .02), and younger donor age (OR, 0.99; 95% CI, 0.99-1.00; P = .03). The following significantly reduced the odds of surviving to 5 years: mechanical ventilation (OR, 0.48; 95% CI, 0.33-0.71; P < .001), hypertension (OR, 0.79; 95% CI, 0.69-0.91; P = .001), and diabetes (OR, 0.79; 95% CI, 0.67-0.92; P = .003). Ventricular assist device data were only available for 2538 patients (49.6%). When added to the multivariate model, the use of a ventricular assist device significantly reduced the odds of surviving 5 years after OHT (OR, 0.63; 95% CI, 0.50-0.81; P < .001)., Conclusions: In the present study of more than 5000 elderly OHT patients, younger recipient age, white race, lower creatinine, younger donor age, and shorter ischemic time were associated with improved 5-year survival. In contrast, bridging with a ventricular assist device, mechanical ventilation, hypertension, and diabetes significantly decreased the odds of 5-year survival. These findings might be useful for prognostication in this higher risk patient population., (Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: We developed a validated 50-point recipient risk index predicting short-term mortality after orthotopic heart transplant (OHT). This study examined the relationship between institutional volume and recipient risk on post-OHT mortality., Methods: We used United Network for Organ Sharing (UNOS) data to identify primary OHT recipients between January 2000 and April 2010. Centers were stratified by mean annual volume. Preoperative Index for Mortality Prediction After Cardiac Transplantation risk scores were calculated for each patient with our validated 50-point system. Primary outcomes were 30-day and 1-year survivals. Multivariable logistic regression analysis included interaction terms to examine effect modification of risk and volume on mortality., Results: In all, 18,226 patients underwent transplant at 141 centers: 1173 (6.4%) recipients at low-volume centers (<7 procedures/y), 5353 (29.4%) at medium-volume centers (7-15 procedures/y), and 11,700 (64.2%) at high-volume centers (>15 procedures/y). Low center volume was associated with worse 1-year mortality (odds ratio, 1.58; 95% confidence interval, 1.30-1.92; P < .001). For 1-year survival, there was significant positive interaction between center volume and recipient risk score (odds ratio, 1.04; 95% confidence interval, 1.01-1.07; P = .02), indicating effect of risk on mortality at low-volume centers greater than from either variable analyzed individually. Among high-risk recipients (score ≥10), 1-year survival was improved at high-volume centers (high, 79%; medium, 75%; low, 64%)., Conclusions: In analysis of UNOS data with our validated recipient risk index, institutional volume acted as an effect modifier on association between risk and mortality. High-risk patients had higher mortality at low-volume centers; differences dissipated among lower-risk recipients. These data support a mandate for high-risk transplants at higher-volume centers., (Copyright © 2012. Published by Mosby, Inc.)

Background: Insurance status and education are known to affect health outcomes. However, their importance in orthotopic heart transplantation (OHT) is unknown. The United Network for Organ Sharing (UNOS) database provides a large cohort of OHT recipients in which to evaluate the effect of insurance and education on survival., Methods: UNOS data were retrospectively reviewed to identify adult primary OHT recipients (1997 to 2008). Patients were stratified by insurance at the time of transplantation (private/self-pay, Medicare, Medicaid, and other) and college education. All-cause mortality was examined using multivariable Cox proportional hazard regression incorporating 15 variables. Survival was modeled using the Kaplan-Meier method., Results: Insurance for 20,676 patients was distributed as follows: private insurance/self-pay, 12,298 (59.5%); Medicare, 5,227 (25.3%); Medicaid, 2,320 (11.2%); and "other" insurance, 831 (4.0%). Educational levels were recorded for 15,735 patients (76.1% of cohort): 7,738 (49.2%) had a college degree. During 53 ± 41 months of follow-up, 6,125 patients (29.6%) died (6.7 deaths/100 patient-years). Survival differed by insurance and education. Medicare and Medicaid patients had 8.6% and 10.0% lower 10-year survival, respectively, than private/self-pay patients. College-educated patients had 7.0% higher 10-year survival. On multivariable analysis, college education decreased mortality risk by 11%. Medicare and Medicaid increased mortality risk by 18% and 33%, respectively (p ≤ 0.001)., Conclusions: Our study examining insurance and education in a large cohort of OHT patients found that long-term mortality after OHT is higher in Medicare/Medicaid patients and in those without a college education. This study points to potential differences in the care of OHT patients based on education and insurance status., (Copyright © 2012 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Background: Large national registries lack information on social support, which is increasingly recognized as an important factor associated with improved outcomes after solid-organ transplantation. We examined our institutional database to identify social factors associated with improved outcomes after orthotopic heart transplantation (OHT)., Methods: Outcomes of OHT patients from 1995 to 2010 at our institution were retrospectively reviewed. Clinical data and social information were extracted from medical records. Patients were stratified by marital status at time of OHT listing. The examined outcome was 5-year survival, excluding deaths within 60 days, modeled using the Kaplan-Meier method. A Cox multivariable hazard regression model was constructed to assess the effect on 5-year survival., Results: Of 260 OHT recipients, 176 (68%) were men. Mean age was 49 ± 12 years and mean body mass index was 26.8 ± 5.0 kg/m(2). At the time of OHT listing, 175 patients (68%) were married. Before OHT, 25% were supported with ventricular assist devices and 17% were in the intensive care unit. Conditional Kaplan-Meier analysis revealed improved 5-year survival for married patients (84%) compared with unmarried patients (69%). After risk-adjustment with Cox analysis, being married improved 5-year survival (hazard ratio [HR], 0.47; 95% confidence interval [CI], 0.23-0.97; p = 0.042) and also improved 1-year survival (p = 0.02). Other social support variables (children, grandchildren, living arrangements, education, race, employment status) were not associated with mortality., Conclusions: Married patients have improved survival after OHT compared with unmarried patients. Being married confers a powerful 5-year survival advantage after OHT. This benefit appears mediated by an improvement in survival during the first post-transplant year., (Copyright © 2011 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Objective: Preformed anti-human leukocyte antigen antibodies have been associated with prolonged wait times and increased mortality in orthotopic heart transplantation. We used United Network for Organ Sharing data to examine panel reactive antibody titers in patients bridged to transplant with left ventricular assist devices., Methods: This was a retrospective review of the United Network for Organ Sharing dataset for all patients bridged to orthotopic heart transplantation with a HeartMate II or HeartMate XVE (Thoratec Corp, Pleasanton, Calif) from January 2004 to December 2009. Patients were primarily stratified by device type and secondarily grouped for comparisons by high (>25%) versus low (0%) panel reactive antibody activity (class I and II). Outcomes included survival (30-day and 1-year), treated rejection in the year after orthotopic heart transplantation, and primary graft dysfunction. Cox proportional hazards regression examined 30-day and 1-year survival., Results: A total of 871 patients (56.1%) received the HeartMate II device, and 673 patients (43.9%) received the HeartMate XVE device. Patients with high panel reactive antibody had longer duration on the wait list (205 days [interquartile range, 81-344] vs 124 days [interquartile range, 51-270], P = .01). High panel reactive antibody class II was more common in patients with the HeartMate XVE device (51/547 [9.3%] vs 42/777 [5.4%], P < .001). When the entire cohort was examined together, there was no 30-day or 1-year survival difference based on panel reactive antibody activity. Device type did not affect post-orthotopic heart transplantation survival, and panel reactive antibody activity was not associated with worse mortality in Cox regression. Although panel reactive antibody activity did not affect rejection in the year after orthotopic heart transplantation for either device type, high panel reactive antibody class II was associated with higher rates of primary graft dysfunction for both devices (P < .05)., Conclusions: This is the largest modern study to examine the impact of detailed panel reactive antibody information in patients bridged to transplant. High panel reactive antibody levels do not affect drug-treated rejection episodes in the first year post-orthotopic heart transplantation; however, there is an associated higher rate of primary graft dysfunction, regardless of device type. Highly sensitized patients bridged to transplant experience excellent survival outcomes after orthotopic heart transplantation., (Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: No recipient risk index exists predicting short-term mortality after orthotopic heart transplantation (OHT). We utilized United Network for Organ Sharing (UNOS) data to develop a novel quantitative recipient risk score for use in OHT., Methods: A prospectively collected open cohort of 21,378 primary OHT patients (1997 to 2008) was randomly divided into subgroups. The training cohort (n=17,079) was used for score derivation and the test cohort (n=4,299) was used for independent validation. Recipient specific variables associated with 1-year mortality (exploratory p value<0.2) were incorporated stepwise into a multivariable logistic regression model. The final model contained variables which maximized explanatory power (assessed by pseudo R2, area under the curve, and likelihood-ratio test). A risk index was created by apportioning points approximating the relative impact of variables on 1-year mortality. The Kaplan-Meier method was used to assess impact of risk score on short-term survival., Results: The 50-point scoring system incorporated 12 recipient specific variables. Derivation and validation cohort scores ranged from 0 to 33 and 0 to 27, respectively (mean 6.1±3.7 and 6.1±3.7). Each point increased the odds of 1-year death by 14% in the derivation cohort (odds ratio 1.14 [1.13 to 1.15], p<0.001) and 15% in the validation cohort (odds ratio 1.15 [1.12 to 1.17], p<0001). One-year survivals in the validation cohort (by increments of 3 points) were the following: 0 to 2 (92.5%); 3 to 5 (89.9%); 7 to 9 (86.3%); and 10 or greater (74.9%); p<0.001. Patients transplanted with risk scores of 20 or higher had 1-year mortality rates greater than 50%., Conclusions: We present a novel internally validated OHT recipient risk score, which is highly predictive of 1-year mortality. This risk index may prove valuable for patient prognosis, organ allocation, and research stratification in OHT., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: 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)., Methods: 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 age >50 years or ischemic time >4 hours). Risk-adjusted multivariate Cox proportional hazard regression was used to assess survival., Results: 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%, p < 0.01). These survival differences persisted on multivariate analysis at 30 days (HR 1.47 [1.02 to 2.13], p < 0.05) and 1 year (HR 1.40 [1.14 to 1.73], p < 0.01). 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%, p < 0.01) and at 1 year (84.2% vs 80.19%, p < 0.01), a difference that was significant according to multivariate Cox analysis at 30 days (HR 2.29 [1.39 to 3.76], p < 0.01) and 1 year (HR 1.61 [1.17 to 2.21], p < 0.01)., Conclusions: 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., (Copyright © 2011 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Context: Recent emphasis on systems-based approaches to patient safety has led to several studies demonstrating worse outcomes associated with surgery at night., Objective: To evaluate whether operative time of day was associated with thoracic organ transplant outcomes, hypothesizing that it would not be associated with increased morbidity or mortality., Design, Setting, and Participants: We conducted a retrospective cohort study of adult heart and lung transplant recipients in the United Network for Organ Sharing database from January 2000 through June 2010. Primary stratification was by operative time of day (night, 7 PM-7 AM; day, 7 AM-7 PM)., Main Outcome Measures: Primary end points were short-term survival, assessed by the Kaplan-Meier method at 30, 90, and 365 days. Secondary end points encompassed common postoperative complications. Risk-adjusted multivariable Cox proportional hazards regression examined mortality., Results: A total of 27,118 patients were included in the study population. Of the 16,573 who underwent a heart transplant, 8346 (50.36%) did so during the day and 8227 (49.64%) during the night. Of the 10,545 who underwent a lung transplant, 5179 (49.11%) did so during the day and 5366 (50.89%) during the night. During a median follow-up of 32.2 months (interquartile range, 11.2-61.1 months), 8061 patients (28.99%) died. Survival was similar for organ transplants performed during the day and night. Survival rates at 30 days for heart transplants during the day were 95.0% vs 95.2% during the night (hazard ratio [HR], 1.05; 95% confidence interval, 0.83-1.32; P = .67) and for lung transplants during the day were 96.0% vs 95.5% during the night (HR, 1.22; 95% CI, 0.97-1.55; P = .09). At 90 days, survival rates for heart transplants were 92.6% during the day vs 92.7% during the night (HR, 1.05; 95% CI, 0.88-1.26; P = .59) and for lung transplants during the day were 92.7% vs 91.7% during the night (HR, 1.23; 95% CI, 1.04-1.47; P = .02). At 1 year, survival rates for heart transplants during the day were 88.0% vs 87.7% during the night (HR, 1.05; 95% CI, 0.91-1.21; P = .47) and for lung transplants during the day were 83.8% vs 82.6% during the night (HR, 1.08; 95% CI, 0.96-1.22; P = .19). Among lung transplant recipients, there was a slightly higher rate of airway dehiscence associated with nighttime transplants (57 of 5022 [1.1%] vs 87 of 5224 [1.7%], P = .02)., Conclusion: Among patients who underwent thoracic organ transplants, there was no significant association between operative time of day and survival up to 1 year after organ transplant.

Objectives: The aim of this study was to determine whether results with the HeartMate (HM) II left ventricular assist device (LVAD) (Thoratec Corporation, Pleasanton, California) in a commercial setting are comparable to other available devices for the same indication., Background: After a multicenter pivotal clinical trial conducted from 2005 to 2008, the U.S. Food and Drug Administration approved the HM II LVAD for bridge to transplantation (BTT). A post-approval study was required by the U.S. Food and Drug Administration to determine whether results with the device in a commercial setting are comparable to other available devices for the same indication., Methods: The study was a prospective evaluation of the first 169 consecutive HM II patients enrolled in the national INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) who were listed for transplant or likely to be listed. Patients were enrolled from April through August 2008 at 77 U.S. centers and followed for at least 1 year after implant. A comparison group (COMP) included all patients (n = 169 at 27 centers) enrolled in the INTERMACS registry with other types of LVADs (79% HeartMate XVE, 21% Implantable Ventricular Assist Device [Thoratec Corporation]) for the same BTT indication in the same time period. Survival rates, adverse events, and quality of life with the EuroQol EQ-5D visual analog scale were obtained in the INTERMACS registry., Results: Baseline characteristics were similar, but creatinine and blood urea nitrogen were lower in the HM II versus COMP groups, and there were fewer patients in the highest-risk INTERMACS patient profile Number 1 (24% for HM II vs. 39% for COMP). Adverse event rates were similar or lower for HM II versus COMP for all events. Bleeding was the most frequent adverse event for both groups (1.44 vs. 1.79 events/patient-year). Operative 30-day mortality for HM II was 4% versus 11% for COMP. The percentage of patients reaching transplant, cardiac recovery, or ongoing LVAD support by 6 months was 91% for HM II and 80% for COMP, and the Kaplan-Meier survival for patients remaining on support at 1 year was 85% for HM II versus 70% for COMP. Quality of life was significantly improved at 3 months of support and sustained through 12 months in both groups compared with baseline., Conclusions: The results in a post-market approval, actual patient care setting BTT population support the original findings from the pivotal clinical trial regarding the efficacy and risk profile of the HM II LVAD. These data suggest that dissemination of this technology after approval has been associated with continued excellent results., (Copyright © 2011 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

End-stage allograft failure following cardiac transplantation is a devastating problem, and retransplantation offers the only chance for survival. We present the case of a young man with a failing cardiac allograft who underwent allograft cardiectomy, atrial pouch formation, and biventricular assist device (BiVAD) placement as a salvage maneuver., (© 2011 Wiley Periodicals, Inc.)

Mycotic pseudoaneurysm is a rare complication after orthotopic heart transplantation (OHT). This case describes a middle-aged OHT recipient who developed a mycotic pseudoaneurysm after an episode of acute cholecystitis. The region of involved aorta was effectively repaired using a patch of bovine pericardium and a brief period of hypothermic circulatory arrest., (© 2010 Wiley Periodicals, Inc.)

Objective: Although left ventricular assist devices (LVADs) are associated with excellent outcomes in patients with end-stage heart failure, there are conflicting reports on posttransplant survival in these patients. Furthermore, prior studies with pulsatile LVADs have shown that transplantation, either early (<6 weeks) or late (>6 months) after LVAD implantation, adversely affected post-cardiac transplant survival. We sought to determine factors related to posttransplant survival in patients supported with continuous-flow LVADs., Methods: The HeartMate II LVAD (Thoratec Corporation, Pleasanton, Calif) was implanted in 468 patients as a bridge to transplant at 36 centers in a multicenter trial. Patients who underwent transplantation after support were stratified by demographics: gender, age, etiology, body mass index, duration of device support, and by adverse events during support. The median age was 54 years (range 18-73 years); 43% had ischemic etiology, and 18% were women. Survival was determined at the specific intervals of 30 days and 1 year after transplantation., Results: Of 468 patients, 250 (53%) underwent cardiac transplant after a median duration of LVAD support of 151 days (longest: 3.2 years), 106 (23%) died, 12 (2.6%) recovered ventricular function and the device was removed, and 100 (21%) were still receiving LVAD support. The overall 30-day and 1-year posttransplant survivals were 97% and 87%. There were no significant differences in survival based on demographic factors or LVAD duration of less than 30 days, 30 to 90 days, 90 to 180 days, and more than 180 days. Patients requiring more than 2 units of packed red blood cells in 24 hours during LVAD support had a statistically significant decreased 1-year survival (82% vs 94%) when compared with patients who did not require more than 2 units of packed red blood cells in 24 hours during LVAD support (P = .03). There was a trend for slightly lower survival at 1 year in patients with percutaneous lead infections during LVAD support versus no infection (75% vs 89%; P = .07)., Conclusions: Post-cardiac transplant survival in patients supported with continuous-flow devices such as the HeartMate II LVAD is equivalent to that with conventional transplantation. Furthermore, posttransplant survival is not influenced by the duration of LVAD support. The improved durability and reduced short- and long-term morbidity associated with the HeartMate II LVAD has reduced the need for urgent cardiac transplantation, which may have adversely influenced survival in the pulsatile LVAD era. This information may have significant implications for changing the current United Network for Organ Sharing criteria regarding listing of heart transplant candidates., (2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Evidence exists for race-linked discrepancies in survival after orthotopic heart transplantation (OHT). The United Network for Organ Sharing database provides an opportunity to examine the effect of race on outcomes in a large cohort of adult OHT patients., Methods: We retrospectively reviewed the United Network for Organ Sharing data for 20,185 adult patients receiving primary OHT (1997 through 2007). Patients were divided into groups of specific race and also stratified by donor and recipient race-matching. The impact of race on mortality was examined using multivariable Cox proportional hazard regression analysis incorporating 23 variables and interaction terms between donor and recipient race. Mortality (30 days, 90 days, 1 year, 2 years, and 5 years) and rejection in the first year were examined. Cumulative post-OHT survival was modeled using the Kaplan-Meier method., Results: Of 20,185 patients, 12,381 (61%) were race matched (75% of whites, n = 11,456; 17% of African Americans, n = 514; 30% of Hispanics, n = 391; 5% of Asians, n = 19). Five thousand six hundred fourteen patients (28%) died during the study. African American recipients have an 11.4% absolute decrease in 10-year survival compared with whites. After risk adjustment, African American recipients have a 46% increase in the risk of cumulative mortality (hazard ratio, 1.46; 95% confidence interval, 1.24 to 1.72; p < 0.001). Decreased survival in African American recipients was not improved with race-matched OHT, nor was there a survival advantage with race-matching in any racial subgroup. Decreased survival in African American recipients persisted after censoring deaths in the first year., Conclusions: Our study represents the largest modern cohort evaluating race in adult OHT. African American recipients have significantly worse survival after OHT. Race-matching did not confer improved survival., (2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: It is unknown whether obesity affects organ allocation in orthotopic heart transplantation (OHT). The United Network for Organ Sharing (UNOS) database provides an opportunity to examine this issue., Methods: We reviewed UNOS data to identify 27,002 OHT candidates placed on the heart transplantation wait list (1998 to 2007). Patients were stratified by body mass index (BMI) at listing. Multivariate Cox proportional hazards model estimated the chance of receiving OHT, adjusting for factors that might affect allocation. Mortality on the wait list and post-OHT mortality were estimated using the Kaplan-Meier method., Results: Of 27,002 patients listed, the distribution of BMI was as follows: BMI 18.5 to 24.9, n = 9,734 (36.0%); BMI 25 to 29.9, n = 10,063 (37.2%); BMI 30 to 34.9, 5,500 (20.4%); and BMI > or =35, 1,705 (6.3%). BMI was strongly associated with a decrease in the likelihood of receiving OHT once on the wait list (hazard ratio [HR] 0.96, 95% confidence interval [CI] 0.95 to 0.96, p < 0.001). Patients with BMI > or =35 had a 46% lower likelihood of receiving a donor heart after risk adjustment (HR 0.54, 95% CI 0.49 to 0.60, p < 0.001). On the wait list, patients with extreme BMIs (> or =35) who were listed as UNOS Status 1 had the lowest cumulative survival (61% at 3 years). After OHT, patients with high BMI did not have increased short-term mortality at 30 days, 90 days or 1 year., Conclusions: Obese individuals wait longer and have a lower likelihood of receiving a donor heart after listing, despite similar short-term survival. The results of this study point to a potential provider bias for obese individuals in OHT.

Introduction: Single-institution series have suggested that men receiving orthotopic heart transplantation from female donors have decreased survival. No multi-institutional series has comprehensively addressed the issue of donor and recipient sex matching for both male and female orthotopic heart transplantation recipients., Methods and Results: We used data from the multi-institutional prospectively collected United Network for Organ Sharing open transplantation cohort to review 18 240 adult patients who received orthotopic heart transplantation from 1999 to 2007. Four donor recipient strata were identified (male donor/male recipient, N=10 750; female donor/female recipient, N=2201; male donor/female recipient, N=2121; and female donor/male recipient, N=3168). The primary end point of all cause posttransplant mortality was compared among groups using a Cox proportional hazard regression model with additional propensity adjustment. Female recipients, irrespective of donor sex, had 3.6% lower overall survival at 5 years posttransplant (P=0.003). Men who received organs from male donors had the highest cumulative survival at 5 years (74.5%). Men receiving female hearts had a 15% increase in the risk of adjusted cumulative mortality (hazard ratio, 1.15; 95% CI, 1.02 to 1.30; P=0.02). No significant increase in the relative hazard for death occurred for women receiving opposite sex donor organs (1.24; 0.92 to 1.35; P=0.31)., Conclusions: The United Network for Organ Sharing data set has provided a large sample examining donor recipient sex pairing in orthotopic heart transplantation. Men receiving organs for same sex donors have significantly improved short- and long-term survival. No survival advantage was seen for women with same sex donors.

Background: Congenital heart disease (CHD) in the adult is an uncommon indication for heart transplantation but has been increasing. We assessed survival and predictors of death after heart transplantation for adults with CHD., Methods: Adult primary heart transplant recipients (aged > 17 years) reported to the United Network for Organ Sharing (1987 to 2006) were reviewed and categorized by diagnosis of CHD vs other diagnoses. Kaplan-Meier survival analysis and Cox regression modeling were performed., Results: During the study period, 35,334 adults underwent primary heart transplantation, and 689 (2%) had CHD. Adult CHD recipients had longer mean waiting list time (218 vs 195 days; p = 0.004), longer ischemic time (3.5 vs 2.9 hours, p < 0.0001), and were more likely to have pretransplant pulmonary vascular resistance exceeding 4 Woods Units (62% vs 51%, p < 0.0001) vs other recipients. Thirty-day mortality was 16% vs 6% (p < 0.0001), although Kaplan-Meier survival did not differ between groups (p = 0.92) out to 10 years. Ischemic time (hazard ratio [HR], 1.2; 95% confidence interval [CI], 1.02 to 1.35; p = 0.02), African American race (HR, 1.9; 95% CI, 1.04 to 3.58; p = 0.03), and pulmonary vascular resistance exceeding 4 Woods Units (HR, 1.5; 95% CI, 1.01 to 2.19; p = 0.04) were predictors of death for adult CHD recipients., Conclusions: Heart transplantation for adults with CHD is effective and has good long-term prognosis. The 30-day mortality rate is high, but 5- and 10-year survival is not statistically different from patients without CHD.

Cardiac allotransplantation is subject to a number of chronic complications that may limit graft survival. These include allograft coronary artery disease, renal dysfunction, hypertension, and malignancy, which are largely due to the immuno-modulatory and adverse effects of transplant medications. Reoperation for native allograft disease progression is a rarer phenomenon. We report a case of aortic valve replacement for bicuspid aortic valve stenosis that occurred in a patient more than ten years after cardiac transplantation.

Background: Left ventricular assist devices (LVADs) are an important therapy for selected individuals with advanced heart failure unable to wait for a suitable donor for transplantation. Pulsatile LVADs are associated with commissural fusion of the aortic valve, yet little is known about this association with newer generation continuous axial flow LVADs., Methods: We retrospectively reviewed pathologic samples from 9 patients enrolled in the HeartMate II Bridge to Transplantation Trial. Echocardiograms at 1, 6 and 12 months after device placement were evaluated for aortic valve opening and aortic insufficiency. At the time of transplantation, explanted hearts were examined for gross pathologic valvular abnormalities and histologic analysis., Results: All but 1 explant had evidence of commissural fusion of the native aortic valve leaflets. Over time there was a decreasing prevalence of aortic valve opening and an increasing prevalence of mild to moderate aortic insufficiency independent of pump speed. All patients had improvements in their functional status and were successfully bridged to orthotopic heart transplantation., Conclusions: Commissural fusion of the native aortic valve leaflets occurs frequently with an increasing prevalence of aortic insufficiency during continuous flow LVAD support. With the potential broader use of non-pulsatile LVADs and the prospect of using LVADs as means to assist in myocardial recovery, special attention should be given to evaluating aortic valve function during LVAD support.

Background: The Centers for Medicare and Medicaid Services (CMS) mandate that orthotopic heart transplantation (OHT) centers perform 10 transplants per year to qualify for funding. We sought to determine whether this cutoff is meaningful and establish recommendations for optimal center volume using the United Network for Organ Sharing (UNOS) registry., Methods: We reviewed UNOS data (years 1999 to 2006) identifying 14,401 first-time adult OHTs conducted at 143 centers. Stratification was by mean annual institution volume. Primary outcomes of 30-day and 1-year mortality were assessed by multivariable logistic regression (adjusted for comorbidities and risk factors for death). Sequential volume cutoffs were examined to determine if current CMS standards are optimal. Pseudo R2 and area under the receiver operating curve assessed goodness of fit., Results: Mean annual volume ranged from 1 to 90. One-year mortality was 12.6% (n = 1,800). Increased center volume was associated with decreased 30-day mortality (p < 0.001). Decreased center volume was associated with increases in 30-day (odds ratio [OR] 1.03, 95% confidence interval [CI]: 1.02 to 1.03, p < 0.001) and 1-year mortality (OR 1.01, 95% CI: 1.01 to 1.02, p = 0.03--censored for 30-day death). The greatest mortality risk occurred at very low volume centers (

Background: Generally accepted donor criteria for heart transplantation limit allografts from donors within approximately 20% to 30% of the recipient's weight. We analyzed the impact of donor-to-recipient weight ratio on survival after heart transplantation., Methods and Results: Adult heart transplant recipients reported to the United Network for Organ Sharing from 1999 to 2007 were divided into 3 groups based on donor-to-recipient weight ratio: <0.8, 0.8 to 1.2, and >1.2. Kaplan-Meier methodology was used to estimate survival. Propensity-adjusted Cox regression modeling was used to analyze predictors of mortality. A total of 15 284 heart transplant recipients were analyzed; 2078 had weight ratio of <0.8, 9684 had 0.8 to 1.2, and 3522 had >1.2. Kaplan-Meier survival was not statistically different between groups at 5 years (P=0.26). Among patients with weight ratio <0.8, 5-year survival was lower for recipients with high pulmonary vascular resistance (>4 Woods units; P=0.02). Among recipients with high pulmonary vascular resistance, 5-year survival was similar for those with weight ratio 0.8 to 1.2 and >1.2 (P=0.44). Furthermore, male recipients with elevated pulmonary vascular resistance who received hearts from female donors had a significantly worse survival than males who received hearts from male donors (P=0.01). Propensity-adjusted multivariable analysis demonstrated that weight ratio <0.8 did not predict mortality (hazard ratio, 1.09; 95% CI, 0.94 to 1.27; P=0.21). Five-year survival after propensity matching was not statistically different between those with weight ratio <0.8 versus >/=0.8 (P=0.37)., Conclusions: Weight ratio did not predict mortality after heart transplantation. However, recipients with elevated pulmonary vascular resistance who received undersized hearts had poor survival. Furthermore, in the setting of high pulmonary vascular resistance, male recipients who received hearts from female donors had worse survival than those who received hearts from male donors. Extending donor criteria to include undersized hearts in select recipients should be considered.

Background: Cardiac transplantation is the accepted standard treatment for end-stage heart disease but is donor limited. Surgical ventricular remodeling is an established treatment for patients with ischemic cardiomyopathy. We sought to compare charges, outcomes, and survival in patients undergoing surgical ventricular restoration (SVR) versus cardiac transplantation (CTx)., Methods and Results: We retrospectively analyzed hospital charges, length of stay (LOS), and survival for 69 SVR and 53 CTx patients at our institution between January 2002 and June 2005. We also compared New York Heart Association (NYHA) status and Kaplan-Meier survival of our SVR patients with CTx patients with ischemic cardiomyopathy from the International Society of Heart & Lung Transplantation (ISHLT) registry. Median total LOS (12 days vs. 17 days, P = .01) and median postoperative LOS (10 days vs. 15 days, P = .02) were shorter for SVR patients than our CTx patients. Median total hospital charges ($45,506 vs. $137,679, P < .0001) and median total drug charges ($2,625 vs. $15,930, P < .0001) were lower for SVR patients. Significant improvements in ejection fraction were seen after both SVR (27% vs. 37%; P < .0001) and CTx (14% vs. 62%, P < .0001). Furthermore, 91% (49/54) of surviving SVR patients, 98% (44/45) of surviving CTx patients, and 91% of ISHLT CTx patients improved to NYHA Class I/II at follow-up. Survival did not differ between groups., Conclusions: SVR patients demonstrate cost-effective clinical improvements that lead to good overall survival. SVR is an excellent surgical option for CHF patients who are not transplant candidates, and should be considered for ischemic cardiomyopathy patients who qualify for transplantation. This strategy may help relieve donor shortage and improve allocation of donor organs.

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 < 0.001) and shorter LOS (19 vs 21 days, p < 0.001)., 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.

Background: Panel-reactive antibody (PRA) screening to detect HLA antibodies is an important part of evaluation for potential heart transplant recipients. We sought to determine how different levels of PRA affect outcomes in heart transplantation., Methods: A retrospective cohort study of using data reported to the United Network for Organ Sharing/Organ Procurement and Transplantation Network (UNOS/OPTN) registry from January 1, 2000, to December 31, 2004, was performed. The association between PRA at transplant and primary end points, allograft and patient survival, as well as a secondary end point, rejection within 1 year, was analyzed., Results: Pretransplant PRA was reported for 8,160 (79.4%) of the 10,279 first heart transplant recipients during the study period. Panel-reactive antibody was 0% in 6,481 (79.4%) patients (group 1), 1% to 10% in 930 (11.4%) patients (group 2), 11% to 25% in 309 (3.8%) patients (group 3), and greater than 25% in 440 (5.4%) patients (group 4). Actuarial survival was significantly different among the four groups by Kaplan-Meier method (p < 0.001). Furthermore, using PRA cutoffs of 0%, 10%, or 25%, the group with lower PRA had significantly better patient and allograft survival. Cox proportional hazard modeling revealed increasing PRA as a significant predictor of mortality (p < 0.001). However, when each group (2, 3, and 4) was compared with group 1 (PRA 0%), only group 4 (PRA > 25%) had worse survival on multivariate analysis. Patients with PRA greater than 25% confirmed by the flow cytometric technique had the worst overall survival. Rejection rate within 1 year after transplantation also significantly increased with increasing PRA. Propensity-matched patients demonstrated similar results., Conclusions: This large series of patients from the United Network for Organ Sharing database has demonstrated that elevated PRA remains a significant risk factor in a recent cohort of heart transplant recipients. Patients with PRA greater than 25% are at a particularly high risk.

Antibody-mediated rejection (AMR) in human heart transplantation is an immunopathologic process in which injury to the graft is in part the result of activation of complement and it is poorly responsive to conventional therapy. We evaluated by immunofluorescence (IF), 665 consecutive endomyocardial biopsies from 165 patients for deposits of immunoglobulins and complement. Diffuse IF deposits in a linear capillary pattern greater than 2+ were considered significant. Clinical evidence of graft dysfunction was correlated with complement deposits. IF 2+ or higher was positive for IgG, 66%; IgM, 12%; IgA, 0.6%; C1q, 1.8%; C4d, 9% and C3d, 10%. In 3% of patients, concomitant C4d and C3d correlated with graft dysfunction or heart failure. In these 5 patients AMR occurred 56-163 months after transplantation, and they responded well to therapy for AMR but not to treatment with steroids. Systematic evaluation of endomyocardial biopsies is not improved by the use of antibodies for immunoglobulins or C1q. Concomitant use of C4d and C3d is very useful to diagnose AMR, when correlated with clinical parameters of graft function. AMR in heart transplant patients can occur many months or years after transplant.

Background: Continuous hypothermic perfusion is a novel cardiac preservation technique. Reactive oxygen species play a role in ischemia reperfusion injury and limit organ preservation. Oxidative stress mediates a DNA mismatch lesion (7, 8-dihydro-8-oxoguanine [8-oxo-G]), which is repaired by the enzymes MutY homologue (MYH), 8-oxo-G glycosylase (OGG1), and MutS homologue 2 (MSH2). We hypothesized that continuous hypothermic perfusion would allow for maintenance of cardiac function while attenuating myocardial DNA damage with respect to the current clinical practice of static preservation at 4 degrees C., Methods: In our canine orthotopic transplant model, donor hearts were harvested after echocardiograms, and hemodynamic studies were obtained and served as controls. The hearts were transplanted after 24 hours of continuous hypothermic perfusion or 4 hours of static preservation, and were studied for 6 hours. Quantification of 8-oxo-G lesions, MYH, OGG1, and MSH2 concentrations were performed on biopsies using immunohistochemistry., Results: Postimplant echocardiograms, completed in 7 continuously perfused and 8 statically preserved hearts, demonstrated good function and normal wall motion. Positive staining for 8-oxoG was markedly increased in the static preservation group. Staining density for MYH, OGG1, and MSH2 were significantly decreased in statically preserved hearts and equivalent between continuously perfused and control hearts., Conclusions: The DNA damage assayed by 8-oxoG was significantly increased in statically preserved versus continuously perfused hearts. The DNA repair enzymes MYH, OGG1, and MSH2 were also markedly decreased in the static preservation versus continuous hypothermic perfusion groups. Continuous hypothermic perfusion reduces oxidative damage and extends preservation without compromising function.

Background: Pulmonary hypertension (PH) is common in severe heart failure, but the effect of mild PH on posttransplantation PH and survival after heart transplantation has not been well described., Methods: This cohort study examined preoperative and postoperative hemodynamics in 172 heart transplant recipients at Johns Hopkins Hospital followed for up to 15.1 years. PH was defined as pulmonary vascular resistance > or =2.5 Wood units, as measured during routine right heat catheterization; mild to moderate PH was defined as PVR between 2.5 and 4.9 Wood units; and severe PH was defined as PVR > or =5.0 Wood units., Results: Seventy-one patients (41.3%) had PH, mostly of mild/moderate severity (77.5%), at the last routine hemodynamic monitoring before transplantation (median time before transplantation, 2.7 months). During follow-up, 105 patients (62.9%) developed PH at some point after transplantation, and 48 patients died (cumulative incidence, 76.5%). Mild/moderate preoperative PH was associated with increased risk of posttransplantation PH at 1, 3, and 6 months, but not with later episodes of PH. Mild/moderate preoperative PH was not associated with a higher mortality rate, but each 1 Wood unit increase in preoperative PVR demonstrated a trend toward increased mortality. Severe preoperative PH was associated with death within the first year after adjusting for potential confounders, but not with overall mortality or mortality at other time points., Conclusions: Mild to moderate preoperative PH is associated with increased risk of developing early but not late posttransplantation PH and may suggest different management strategies. Although PH was not consistently associated with mortality, increasing severity of the preoperative PH suggests potentially worse prognosis.

Polyclonal antithymocyte globulin preparations contain antibodies with reactivity to endothelial cells. Therefore, we investigated whether treatment with this reagent caused complement deposition in human cardiac transplants. Frozen tissue was available from endomyocardial biopsies of 75 patients, who were transplanted between April 1995 and April 2000. Nine of these patients were converted from cyclosporin A (CsA) to horse antithymocyte globulin (ATGAM) in the first month after transplantation. All of the biopsies were stained by immunofluorescence for C4d as evidence of activation of the classical pathway of complement. In addition, biopsies from patients treated with ATGAM and control patients were stained for deposition of horse immunoglobulin (Ig)G. All nine patients who received ATGAM had deposition of horse IgG and C4d. Two color stains demonstrated that the horse IgG colocalized with the C4d staining. No staining for horse IgG or C4d was evident in biopsies obtained before ATGAM treatment. Likewise, no staining for horse IgG was detected in seven control patients who had C4d staining. Most patients treated with ATGAM had no histologic evidence of rejection, but did have myocyte damage and macrophage infiltration. Thus prophylactic treatment with ATGAM is associated with the deposition of horse IgG and activation of complement in the transplant.

Introduction: Despite investigating numerous solutions, additives, and techniques over the last two decades, extending donor heart preservation beyond 4-6 h has not been achieved. Hypothermic heart preservation (HP) induces oxidative stress (OS) with reactive oxygen species (ROS) production, causing DNA cleavage and impairing repair. Quantification of cardiomyocyte concentrations of DNA damage by-products (8-oxoG) and mismatch repair enzymes (MYH, OGG-1, MSH2) reflects the severity of OS. If increased repair enzyme production is insufficient to repair injury, cell death occurs and functional outcomes are impacted. We investigated continuous hypothermic perfusion (CHP), a new form of HP, and the mechanism of injury associated with hypothermic storage, by assessing functional outcome and OS after allotransplantation of canine hearts., Methods: Fourteen canine hearts were harvested using standard techniques after baseline echocardiograms and haemodynamic parameters were obtained. The hearts were implanted after 24 h CHP (n = 10) or 4 h static preservation (SP; n = 4). After weaning from cardiopulmonary bypass (CPB), recipients were kept alive for 6 h. Repeat echocardiograms and haemodynamic parameters were obtained. Quantification of MYH, OGG-1, and MSH2 concentrations were performed on biopsies using immunohistochemistry and Western blot analysis., Results: Twelve out of 14 hearts (8/10 CHP; 4/4 SP) were successfully weaned on moderate inotropic support. Post-implant echocardiogram, completed in 6/10 CHP and 2/4 SP hearts, demonstrated hyperdynamic function and normal wall motion. The expression and activity of DNA repair enzymes was identical between normal baseline and CHP hearts., Conclusion: CHP reduces OS associated with prolonged hypothermic preservation and may allow longer preservation periods without compromising function. CHP offers several potential advantages: (1) resuscitation of non-beating heart donor organs, (2) time for HLA tissue typing, (3) facilitate interventions improving graft function, and (4) increased organ sharing.

The increasingly severe shortage of donor hearts has prompted a liberalization of what is considered an acceptable donor heart. The use of marginally acceptable organs has increased in recent years. Although these marginal donors have proved effective, there still remains a tremendous shortage of donors to treat the large number of patients who are candidates for cardiac transplantation. Further use of marginal donors is limited by the requirement to assume immediate and full support of the circulation. New strategies are required to increase donor organ use even further. The authors developed a model of heterotopic abdominal heart transplant (HAHT) to investigate the possibility of using marginal donor hearts to expand the donor pool for cardiac transplantation. The authors' goal was to show that HAHT was technically feasible and could potentially function as auxiliary circulatory support in the setting of low cardiac output. The hemodynamic and metabolic consequences of a HAHT were investigated in a pilot study that provides proof of concept and lays the groundwork for future investigations.