Search

Demand for donor hearts persistently outstrips supply. To expand the donor pool, in the past four years, US centers have transplanted hearts procured from donors after circulatory death (DCD). DCD heart recipients frequently exhibit early, clinically significant, but reversible right ventricular dysfunction (RVD), but little is known about how this impacts post-transplant renal function. We evaluated whether DCD transplantation is associated with early renal dysfunction as compared to recipients receiving standard of care (SOC) hearts donated after brain death (DBD). All patients at a single center who were not on dialysis and underwent single-organ cardiac transplantation from April 2016 to August 2022 were included. Renal metrics collected included final pre-transplantation creatinine and peak creatinine within seven days after transplantation; these were converted to eGFR using the CKD-Epi 2021 Race-Free GFR equation. Acute kidney injury (AKI) was defined as a 1.5-fold rise in creatinine within seven days. RA pressure was measured via right heart catheterization on day seven after transplant. Data were statistically analyzed with two-tailed t-tests, chi-squared tests, and Pearson's correlation coefficients, as appropriate. 228 patients (171 SOC and 57 DCD) were included. Baseline characteristics were similar between groups. Nadir eGFR in the first week post-transplantation was similar between DCD and SOC (50.4 ± 28.0 mL/min vs 48.1 ± 25.8 mL/min; p=0.58), as were rates of AKI (49.1% vs 46.2%; p=0.92) and use of CVVH (7.0% vs 5.3%; p=0.89). DCD patients had higher RA pressures on day seven post-transplant (10.0 ± 4.2 mmHg vs 8.2 ± 4.7 mmHg for SOC; p=0.01); the inverse relationship between RA pressures and nadir post-transplantation eGFR in DCD patients was not significant (r=-0.25; p=0.07). While transplantation using DCD hearts is associated with early RVD, no adverse impact on early renal outcomes compared to SOC recipients was observed. [ABSTRACT FROM AUTHOR]

The United Network for Organ Sharing (UNOS) policy governing heart transplantation priority changed in October 2018 and is now less favorable to patients with durable left ventricular assist devices (LVADs). This study endeavored to assess differences in demographics and outcomes between patients with durable LVAD undergoing orthotopic heart transplant (OHT) before and after this change in the priority system. A retrospective analysis of 129 patients with durable LVAD who underwent OHT at Massachusetts General Hospital between 2016 and 2022 was performed using site-specific databases for heart transplant and durable LVAD. Patients listed before but transplanted after this policy change were excluded from analysis. 58 patients listed for transplant and transplanted before the policy change 10/18/18 were compared to 71 patients listed and transplanted after 10/18/18. Standard statistical analysis was used to examine baseline characteristics, organ donor characteristics, and post-transplant outcomes. Kaplan-Meier survival curves were generated then compared by log-rank test. 58 patients were included in the Old Listing Criteria group, and 71 patients were included in the New Listing Criteria group. There were no significant differences in gender (74.14% male vs 76.06% male, p=0.306), age (55.1 vs 57.4, p=0.802), or race (p=0.402). More patients in the New Listing Criteria group were implanted with an LVAD as destination therapy then listed for OHT afterwards compared to the Old Listing Criteria group (92.96% vs 53.45%, p=0.000). There was no significant difference in 1-year mortality. There were no significant differences in ejection fraction, cardiac index, or pulmonary capillary wedge pressure in the near-term post-operative period between the two groups. Patients with LVAD who underwent OHT before and after the decreased prioritization of LVAD patients 10/18/18 were similar demographically and did not have clinically significant differences in outcomes suggesting that LVAD therapy remains a reasonable consideration as a bridge to transplant. [ABSTRACT FROM AUTHOR]

Hepatitis C (HCV) has become readily treatable in the modern era. The use of HCV+ organs for transplant has shown promising results and increases donor availability. This study is an updated analysis of outcomes after HCV+ heart transplantation in the United States. The United Network for Organ Sharing registry was queried for adult patients who received heart transplants from 2015-2018. Excluded multiorgan transplants, incomplete HCV data, and loss to follow-up. HCV status was classified by serology (Ab+ vs Ab-). Median follow-up was 24 months. During the study period, 7529 patients received heart transplants: 136 from HCV Ab+ donors and 7393 from HCV Ab- donors. Seven recipients (5.1%) of HCV Ab+ hearts had HCV+ serology prior to transplant, compared to 129 recipients (1.7%) of HCV Ab- organs (p=0.018). There was no difference in donor age (p=0.489), ejection fraction (p=0.221), gender mismatch (p=0.341), or ABO compatibility (p=0.707). HCV Ab+ transplants involved further travel (mean: 323 vs 149 miles, p<0.001) with longer ischemic times (mean: 3.55 vs 3.03 hours, p<0.001) due to regional variation in use of HCV+ organs. Kaplan Meier analysis showed no effect of HCV status on overall survival (p=0.960), and no difference in graft failure (p=0.700). On multivariate Cox regression, HCV status was not a significant predictor of mortality (HR 0.85, 95% CI 0.47-1.56, p=0.601), while overall mortality was affected by HLA mismatch (HR 1.07, 95% CI 1.00-1.14, p= 0.037), donor age (HR 1.01, 95% CI 1.00-1.02, p=0.002), recipient creatinine (HR 1.07, 95% CI 1.04-1.12, p<0.001), and use of ECMO (HR 3.27, 95% CI 2.08-5.12, p<0.001) or a ventricular assist device (HR 1.23, 95% 1.08-1.41, p=0.003) at the time of transplant. Transplantation of HCV+ donor hearts has demonstrated promising outcomes thus far, with comparable overall survival and graft outcomes. Ongoing investigation is warranted to observe long-term outcomes. [ABSTRACT FROM AUTHOR]

Purpose Donor availability has continued to be a major issue limiting the number of cardiac transplantations in the United States. Given this shortage, it is necessary to consider strategies aimed at increasing the donor pool. We sought to evaluate the expanded use of hepatitis C virus (HCV) donor hearts, and characterize early allograft function in HCV-negative patients receiving pre-emptive anti-viral therapy following receipt of an HCV-infected donor heart. Methods Patients who underwent heart transplantation with HCV-positive donors at our institution between November 2017 and October 2018 were studied. Invasive hemodynamic and echocardiographic data were collected from routine scheduled post-transplant procedures. Intensive care unit (ICU) time, time on inotropes and time until discharge were evaluated from the index hospitalization for heart transplantation and compared to data from our center in patients receiving non-HCV hearts between January 2016 and June 2018. Results In total, there have been 23 recipients of donor HCV-positive heart transplants. Cardiac allograft and patient survival has been 100% at a median of 114 (IQR 81-190) days post-transplant. The average time on inotropes was 4.7±3.3 days in recipients of donor HCV-positive heart transplants, average time spent in the ICU was 7.2±4 days in the study group compared with 7.8±7.8 days in patients receiving non-HCV hearts and the average time to discharge was 19 ± 9 days in the study group compared with 21±22 days in patients receiving non-HCV hearts (both p>0.05). Among 80 echocardiograms done on or after post-operative day 2 in recipients of HCV-positive donor hearts, the ejection fraction (EF) was 65±9% with a single value falling below 50% (45%) that normalized 6 days later. One and 8-week hemodynamic values, respectively, were as follows: right atrial pressure of 7±5 and 5±3 mmHg, mean pulmonary arterial pressure of 20±7 and 20±6 mmHg, mean pulmonary capillary wedge pressure of 14±6 and 11±5 mmHg, and cardiac index of 2.8±0.8 and 2.9±0.4 L/min/m2. Conclusion In this single-center prospective study, patients who received preemptive direct-acting antiviral therapy following receipt of an HCV-positive donor heart demonstrated preserved early allograft function post-transplant. [ABSTRACT FROM AUTHOR]