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Heart transplantation 1985-1998: 13-years experience at Angelo De Gasperis Cardio-Thoracic Department-Milan
T Colombo1, E Vitali, M Lanfranconi
1Angelo De Gasperis Cardio-Thoracic Department, Niguarda, Ca' Granda Hospital, Milan, Italy.
Insights
This 13-year heart transplant study shows improved survival rates in recent years. Key risk factors for early mortality include pulmonary hypertension, while late mortality is linked to infections and graft complications.
Area of Science:
- Cardiology
- Transplantation Medicine
- Immunology
Background:
- Analysis of 13 years of heart transplant experience.
- Identification of risk factors for early and late mortality.
Purpose of the Study:
- To analyze heart transplant outcomes over 13 years.
- To identify risk factors influencing patient mortality.
Main Methods:
- Review of data from 461 heart transplant recipients (1985-1998).
- Multivariate logistic regression and Cox's proportional hazard models used to analyze 70 variables.
- Comparison of outcomes between early (1985-1991) and recent (1992-1998) transplant eras.
Main Results:
- Overall mortality was 20.2%; recent era showed lower mortality rates (6.5% early, 6.8% late).
- Graft failure, cardiac allograft vasculopathy, and infection were primary causes of death.
- Actuarial survival was 87.4% at 1 year, 79.2% at 5 years, and 68.9% at 10 years.
- Independent risk factors for early mortality: transpulmonary gradient, right atrial pressure, donor inotropic support.
- Independent risk factors for late mortality: moderate rejections, early posttransplant infections.
Conclusions:
- Significant favorable trend in mortality observed between early and recent transplant eras.
- Pulmonary hypertension and elevated right filling pressure increase early death risk.
- Severe postoperative complications significantly influence late survival.
- Successful outcomes noted in combined heart-kidney transplants and VAD-supported patients.
Background:
After 13 years of transplant experience in our center, we analyzed the results in the overall population and in particular subgroups of heart transplant recipients. We tried to identify risk factors for both early (3 months) and late (over 3 months) mortality after heart transplantation.
Methods:
The data on 461 patients transplanted from November 1985-June 1998 were reviewed. To study risk factors for mortality, the results for 313 patients operated on from June 1985-June 1995 were studied and analyzed with a multivariate logistic regression and Cox's proportional hazard model. Seventy pre-, intra- and postoperative variables were considered including patient demographics, clinical status, hemodynamic parameters, donor characteristics, donor-recipient HLA mismatches, complications, and immunosuppressive protocols. We also compared results for patients transplanted from 1985-1991 (Group 1) and from 1992-1998 (Group II) to assess improvements due to changes in indications and in perioperative treatments.
Results:
Overall mortality in the entire population was 20.2% (93/461). The 30-day, 3-month and late mortality rates were 8.0%, 10.2%, 11.1%, respectively. Group II mortality rates were 6.5%, 8.5% and 6.8%, respectively, despite a significant increase in Status I patients (20.6% in Group I vs 49.0% in Group II, p = 0.0001). The main causes of death were graft failure (24.7%), cardiac allograft vasculopathy (18.3%), and infection (16.1%). The mean follow-up of the 414 recipients who survived more than 3 months was 54.0 +/- 37.3 months. Actuarial survival was 87.4%, 79.2% and 68.9% at one, 5 and 10 years, respectively. The difference in the 5-year actuarial survival rates between Group I and Group II patients was statistically significant (73.5% vs 83.9%, p = 0.0135). The transpulmonary gradient, right atrial pressure and mid-high doses of donor inotropic support were identified as independent risk factors for early mortality. The number of moderate rejections at biopsy and early posttransplant infections were identified as independent risk factors for late mortality. The results of patients transplanted while on ventricular assist devices, urgent and elective patients and combined heart and kidney transplants were also reported.
Conclusions:
The overall results of our 13-year experience are very satisfying in relation to early and late mortality, with a significant favorable trend between patients transplanted in the early era (1985-1991) and those transplanted in the recent era (1992-1998). Pulmonary hypertension and elevated preoperative right filling pressure appear to indicate a significantly increased risk of early death and only marginally influence late survival, which is principally influenced by severe postoperative complications. Good results were achieved in combined heart and kidney transplantation and among patients who deteriorated during the waiting period and were supported with ventricular assist devices. The early and late outcomes for urgent (status I) and elective (status II) heart transplant patients were comparable.