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The proposed donor heart selection guidelines provide evidence-based and expert-consensus recommendations for the selection of donor hearts following brain death. These recommendations were compiled by an international panel of experts based on an extensive literature review. © 2022 International Society for Heart and Lung Transplantation

Decreased exercise capacity portends a poor prognosis in heart failure with preserved ejection fraction (HFpEF). The hemodynamic gain index (HGI) is an integrated marker of hemodynamic reserve measured during exercise stress testing and is associated with survival. The goal of this study was to establish the association of HGI with exercise capacity, serum biomarkers, and echocardiography features in subjects with HFpEF. In 209 subjects with HFpEF enrolled in the RELAX (Phosphodiesterase-5 Inhibition to Improve Clinical Status and Exercise Capacity in Diastolic Heart Failure) trial who underwent cardiopulmonary exercise testing, we calculated the HGI ([peak heart rate [HR] × peak systolic blood pressure [SBP]-[HR at rest × SBP at rest])/(HR at rest × SBP at rest) and tested associations with outcomes of interest. The median (interquartile range) HGI was 0.94 (0.5 to 1.3) beats per min/mm Hg. In multivariable-adjusted linear regression, higher HGI was associated with greater peak oxygen consumption (VO

Cardiac allograft vasculopathy (CAV) causes impaired blood flow in both epicardial coronary arteries and the microvasculature. A leading cause of post-transplant mortality, CAV affects 50% of heart transplant recipients within 10 years of heart transplant.This analysis examined the outcomes of heart transplant recipients with reduced myocardial blood flow reserve (MBFR) and microvascular CAV detected byA total of 181 heart transplant recipients who underwent PET to assess for CAV were included with a median follow-up of 4.7 years. Patients were classified into 2 groups according to the total MBFR:2.0 and ≤2.0. Microvascular CAV was defined as no epicardial CAV detected by PET and/or coronary angiography, but with an MBFR ≤2.0 by PET.In total, 71 (39%) patients had an MBFR ≤2.0. Patients with an MBFR ≤2.0 experienced an increased risk for all outcomes: 7-fold increase in death or retransplantation (HR: 7.05; 95% CI: 3.2-15.6; P 0.0001), 12-fold increase in cardiovascular death (HR: 12.0; 95% CI: 2.64-54.12; P = 0.001), and 10-fold increase in cardiovascular hospitalization (HR: 10.1; 95% CI: 3.43-29.9; P 0.0001). The 5-year mean survival was 302 days less than those with an MBFR2.0 (95% CI: 260.2-345.4 days; P 0.0001). Microvascular CAV (adjusted HR: 3.86; 95% CI: 1.58-9.40; P = 0.003) was independently associated with an increased risk of death or retransplantation.Abnormal myocardial blood flow reserve, even in the absence of epicardial CAV, identifies patients at a high risk of death or retransplantation. Measures of myocardial blood flow provide prognostic information in addition to traditional CAV assessment.

Venous thromboembolism (VTE), such as deep vein thrombosis (DVT) and pulmonary embolism (PE), is an important and serious postoperative complication after heart transplantation. We sought to characterize in-hospital VTE after heart transplantation and its association with clinical outcomes.Adult (≧18 years) patients undergoing heart transplantation from 2015 to 2019 at our center were retrospectively reviewed. Post-transplant VTE was defined as newly diagnosed venous system thrombus by imaging studies.There were 254 patients. The cohort's median age was 55 years. A total of 61 patients were diagnosed with VTE, including one with right atrial thrombus, 54 with upper extremity DVT in which one patient subsequently developed PE, four with lower extremity DVT, and two with upper and lower extremity DVT. The cumulative incidence of VTE was 42% at 60-days of post heart transplant. Patients with VTE had longer hospital stay (P .001), higher in-hospital mortality (P = .010), and worse 5-year survival (P = .009). On the multivariable Cox analysis, history of DVT/PE and intubation for more than 3 days were associated with an increased risk of in hospital VTE.The incidence of VTE in heart transplant recipients is high. Post-transplant surveillance, and appropriate preventive measures and treatment strategies after diagnosis are warranted.

For patients with advanced heart failure, socioeconomic deprivation may impede referral for heart transplantation (HT). We examined the association of socioeconomic deprivation with listing among patients evaluated at our institution and compared this against the backdrop of our local community.We conducted a retrospective cohort study of patients evaluated for HT between January 2017 and December 2020. Patient demographics and clinical characteristics were recorded. Block group-level area deprivation index (ADI) decile was obtained at each patient's home address and Socioeconomic Status (SES) index was determined by patient zip code.In total, 400 evaluations were initiated; one international patient was excluded. Among this population, 111 (27.8%) were women, 219 (54.9%) were White, 94 (23.6%) Black, and 59 (14.8%) Hispanic. 248 (62.2%) patients were listed for transplant. Listed patients had significantly higher SES index and lower ADI compared to those who were not listed. However, after adjustment for clinical factors, ADI and SESi were not predictive of listing. Similarly, patient sex, race, and insurance did not influence the likelihood of listing for HT. Notably, the distribution of the referral cohort based on ADI deciles was not reflective of our center's catchment area, indicating opportunities for improving access to transplant for disadvantaged populations.Although socioeconomic deprivation did not predict listing in our analysis, we recognize the need for broader outreach to combat upstream bias that prevents patients from being referred for HT.

Background: An aging population and improved cancer survivorship have increased the number of individuals with treated malignancy who develop advanced heart failure. The benefits of heart transplantation (HT) in patients with a pretransplant malignancy (PTM) must be balanced against risks of posttransplant malignancy in the setting of immunosuppression. Methods: Adult patients in the United Network for Organ Sharing registry who received HT between January 1, 2010, and December 31, 2020 were included. Trends, patient characteristics, and posttransplant outcomes in HT recipients with PTM were evaluated. Results: From 2000 to 2020, the proportion of HT recipients with PTM increased from 3.2% to 8.2%. From 2010 to 2020, 2113 (7.7%) of 27 344 HT recipients had PTM. PTM was associated with higher rates of 1-year mortality after HT (11.9% versus 9.2%; adjusted hazard ratio, 1.25 [95% CI, 1.09–1.44], P =0.001), driven by increased mortality in patients with hematologic PTM (adjusted hazard ratio, 2.00 [95% CI, 1.61–2.48]; P P Conclusions: Prevalence of PTM in HT recipients nearly tripled over the past 2 decades. Patients with hematologic PTM were at increased risk of early mortality after HT. Patients with PTM were also at higher risk for posttransplant malignancy. Guidelines that reflect contemporary oncological care are needed to inform care of this heterogenous and expanding group of individuals.

Although the burden of end-stage heart failure continues to increase, the number of available organs for heart transplantation (HT) remains inadequate. The HT community has been challenged to find ways to expand the number of donor hearts available. Recent advances include use of hearts from donors infected with hepatitis C virus as well as other previously underutilized donors, including those with left ventricular dysfunction, of older age, and with a history of cocaine use. Concurrently, emerging trends in HT surgery include donation after circulatory death, ex vivo normothermic heart perfusion, and controlled hypothermic preservation, which may enable procurement of organs from farther distances and prevent early allograft dysfunction. Contemporary HT recipients have also evolved in light of the 2018 revision to the U.S. heart allocation policy. This focus seminar discusses recent trends in donor and recipient phenotypes and management strategies for successful HT, as well as evolving areas and future directions.

The 2018 U.S. heart allocation system offers an accelerated pathway for heart transplantation to the most urgent patients.This study sought to determine whether the new allocation system resulted in lower likelihood of candidate recovery.Adult patients waitlisted for heart transplantation with temporary mechanical circulatory support at the time of initial listing between 2010 and 2020 in the United Network for Organ Sharing registry were included. Competing events of heart transplantation, waitlist death or delisting for deteriorating condition, and delisting for improved condition (candidate recovery) were analyzed in the new vs old heart allocation system.A total of 688 patients were waitlisted with venoarterial extracorporeal membrane oxygenation or a surgical nondischargeable biventricular assist device (status 1 or old 1A). Overall, 2,237 patients were waitlisted with an intra-aortic balloon pump, a percutaneous left ventricular assist device (LVAD), or a surgical nondischargeable LVAD (status 2 or old 1A). Patients waitlisted with venoarterial extracorporeal membrane oxygenation or a nondischargeable biventricular assist device had significantly shorter median waitlist times (5 vs 31 days), higher incidence for cardiac transplantation (81.5% vs 43.0%), and lower incidence of candidate recovery (1.5% vs 7.9%) in the new vs old heart allocation system (all P 0.05). Patients waitlisted with an intra-aortic balloon pump or percutaneous or a nondischargeable LVAD also had significantly shorter median waitlist times (8 vs 35 days), higher incidence of transplantation (88.9% vs 64.9%), and lower incidence of candidate recovery (0.2% vs 1.6%) in the new vs old heart allocation system (all P 0.05).Current practice of the new allocation system may not offer select temporary mechanical circulatory support patients the opportunity and adequate time to recover to the point of waitlist removal. Further research will determine which patients would benefit from urgent transplantation vs recovery strategy.

Extracorporeal membrane oxygenation (ECMO) is becoming a key tool for bridge to heart, lung, or heart-lung transplantation, and ambulatory ECMO support offers many advantages to prepare the patients. We here present a case of successful en bloc heart and lung transplantation after long-term ambulatory support with a minimally invasive central venoarterial ECMO approach as bridge to transplant.

Bridge to transplantation (BTT) with left ventricular assist devices (LVADs) is a mainstay of therapy for heart failure in patients awaiting heart transplantation (HT). Criteria for HT listing do not differ between patients medically managed and those mechanically bridged to HT. The objectives of the present study were to evaluate the impact of BTT with LVAD on posttransplantation survival, to describe differences in causes of 1-year mortality in medically and mechanically bridged patients, and to evaluate differences in risk factors for 1-year mortality between those with and those without LVAD at the time of HT.Using the United Network of Organ Sharing database, we identified 5486 adult, single-organ HT recipients transplanted between 2008 and 2015. Patients were propensity matched for likelihood of LVAD at the time of HT. Kaplan-Meier survival estimates were used to assess the impact of BTT on 1- and 5-year mortality. Logistic regression analysis was used to evaluate the odds ratio of 1-year mortality for patients BTT with LVAD compared with those with medical management across clinically significant variables at various thresholds.Early mortality was higher in mechanically bridged patients: 9.5% versus 7.2% mortality at 1 year (P0.001). BTT patients incurred an increased risk of 1-year mortality with an estimated glomerular filtration rate of 40 to 60 mL·minBridge to HT with LVAD, although necessary because of organ scarcity and capable of improving wait list survival, confers a significantly higher risk of early posttransplantation mortality. Patients bridged with mechanical support may require more careful consideration for transplant eligibility after LVAD placement.

Background: There are multiple accepted immunosuppressive medication (ISM) strategies after heart transplant (HT) and evidence of their relative efficacy is limited. As a result, ISM strategies may vary considerably depending on local protocols. We aimed to characterize center-level variation and predictors of ISM strategy. Methods: Using data from the UNOS registry, we included 38,826 patients undergoing HT at 124 US centers from 1994 to 2014; centers with less than 30 transplants during this span were excluded (n=53). ISM strategies included 1) use of anti-lymphocyte induction therapy, 2) omission of corticosteroids (“steroid-free”) in the initial maintenance regimen, and 3) initial inclusion of mTOR inhibitors. Associations between the utilization of each strategy and other center-level characteristics were determined using chi-squared and Pearson correlation tests. Results: The mean center-level proportions of patients receiving induction, steroid-free, and mTOR inhibitor regimens were 50.2% (standard deviation (SD) = 24.6%), 4.3% (SD = 5.6%), and 2.4% (SD = 3.2%) respectively (Figure 1). Many centers (16.1%) used induction in nearly all (> 80%) of their patients and a similar proportion (21.0%) used induction infrequently (in < 20% of patients). While use of mTOR and steroid-free regimens was rare, 10 centers used one or both of these regimens in more than 10% of patients. Centers in the northeast less often used induction and steroid-free regimens were more often used in higher-volume centers (p Conclusions: There is substantial variation across centers in ISM strategy after HT, particularly in the use of induction. This degree of variation is unlikely to be explained by differences in patient mix, and more likely stems from differences in provider preference. Further studies are needed to assess the underlying drivers and clinical impact of this variation.

Background: Socioeconomic and racial disparities in outcomes among patients with heart failure are well-documented. Whether such disparities exist among patients awaiting heart transplant (HT) is unclear. We aimed to characterize the associations of socioeconomic status (SES) and race with outcomes among patients listed for HT. Methods: Patients listed for heart transplant between 1994 and 2014 were included (n = 64,276). SES indicators included insurance status, education, and neighborhood SES (nSES), measured by zip code using a composite index. The primary outcome was a composite of death or delisting and the secondary outcome was transplant. Multivariate analyses were employed to adjust for race, SES, comorbidity, and clinical severity at time of listing. Results: Non-white race, low education, Medicare, Medicaid, and lower nSES (Figure 1) were associated with higher unadjusted risks of death or delisting. After adjustment, the associations with less than high school (HR=1.39) and college education (HR=0.93), Medicare (HR=1.22), Medicaid (HR=1.16), and lowest nSES quartile (HR=1.06) remained significant (p < 0.05; Figure 2). Risks associated with black race and low nSES decreased significantly over time. Adjusted incidence of transplant was significantly lower among blacks (HR = 0.90), but higher among other non-white patients. Conclusions: Low SES is associated with poorer outcomes during HT listing, and there are racial disparities in the likelihood of transplant. Some of these disparities have narrowed over time. Further research is needed to identify the underlying cause of these disparities, which are not explained by measured clinical characteristics.

Background: Given their adverse effects, there is growing interest in omitting corticosteroids from the initial maintenance immunosuppression (IS) regimen after heart transplant (HT). However, evidence for the efficacy of this strategy is limited. Hypothesis: Steroid-free and steroid-containing maintenance regimens are associated with comparable outcomes following HT. Methods: We included patients who received HT between July 2004 and April 2014 and were discharged on an initial maintenance regimen with both tacrolimus and mycophenolic acid, with or without corticosteroids, and with no other IS medications. Patients with rejection or graft failure (death or re-transplant) prior to discharge were excluded. Survival analyses compared outcomes between steroid-free and steroid-treated patients, including time from discharge to graft failure, hospitalization, and infection and rejection requiring hospitalization. Results: Of 10,080 included patients, 15%, 22%, 11%, and 50% experienced graft failure, infection, rejection, and hospitalization, respectively during the follow-up period (2004 - 2014). Steroid-free regimens were used in 8.2%. Steroid-free patients had lower risks of hospitalization (HR = 0.78, p < 0.0001), infection (HR = 0.56, p < 0.0001), and rejection (HR = 0.66, p = 0.018). There was no significant difference in the risk of graft failure (p = 0.12). Conclusions: Steroid-free and steroid-treated patients have comparable graft survival after HT and differ with respect to other selected outcomes. Further research will determine whether this stems from differences in efficacy or patient mix. A steroid-free strategy is likely optimal for selected patients.

A recent study in a mutant mouse model shows that a small molecule can strengthen a critical calcium channel against the effects of chronic adrenergic stimulation and thus prevent ventricular arrhythmia.