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Retransplantation in 7,290 primary transplant patients: a 10-year multi-institutional study
Branislav Radovancevic1, David C McGiffin, Jon A Kobashigawa
1Transplant Research, Texas Heart Institute, Houston 77030, USA.
Insights
Cardiac retransplantation offers survival benefits for coronary allograft vasculopathy but is not advisable for early graft failure or acute rejection. This impacts donor heart allocation strategies.
Area of Science:
- Cardiology
- Transplantation Medicine
- Immunology
Background:
- Cardiac retransplantation remains controversial due to limited donor heart availability.
- A significant disparity exists between the demand for and supply of donor hearts.
Purpose of the Study:
- To evaluate the outcomes and identify risk factors associated with cardiac retransplantation.
- To determine the efficacy of retransplantation for various indications.
Main Methods:
- Analysis of 107 patients who underwent cardiac retransplantation from a cohort of 7,290 primary transplant recipients (1990-1999).
- Retrospective review of data from the Cardiac Transplant Research Database (CTRD).
Main Results:
- Freedom from retransplantation was high (99.2% at 1 year, 96.8% at 10 years).
- Common indications included coronary allograft vasculopathy (CAV), early graft failure, and acute rejection.
- Survival after retransplantation was lower than primary transplantation (56% at 1 year, 38% at 5 years).
- Risk factors for death included retransplantation for acute rejection, early graft failure, and female donor use.
- Retransplantation for CAV showed improved survival over time.
Conclusions:
- Retransplantation for acute rejection and early graft failure is associated with poor outcomes and not recommended.
- Retransplantation for CAV offers satisfactory survival and should be considered for selected patients.
- These findings have implications for donor heart allocation and patient selection for retransplantation.
Background:
Cardiac retransplantation is a controversial procedure due to the disparity between donor heart demand and supply.
Methods:
Of 7,290 patients undergoing primary cardiac transplantation between January 1990 and December 1999 at 42 institutions contributing to the Cardiac Transplant Research Database (CTRD), 106 patients later underwent a second and 1 patient a third cardiac transplant procedure.
Results:
The actuarial freedom from retransplantation was 99.2% and 96.8% at 1 and 10 years, respectively. Reasons for retransplantation included early graft failure (n = 34), acute cardiac rejection (n = 15), coronary allograft vasculopathy (CAV, n = 39), non-specific graft failure (n = 7), and miscellaneous (n = 10). The only risk factor associated with retransplantation was younger age, reflecting the policy of preferential retransplantation of younger patients. Survival after retransplantation was inferior to that after primary transplantation (56% and 38% at 1 and 5 years, respectively). Risk factors associated with death after retransplantation included retransplantation for acute rejection (p = 0.0005), retransplantation for early graft failure (p = 0.03), and use of a female donor (p = 0.005). Survival after retransplantation for acute rejection was poorest (32% and 8% at 1 and 5 years, respectively) followed by retransplantation for early graft failure (50% and 39% at 1 and 5 years, respectively). Survival after retransplantation for CAV has steadily improved with successive eras.
Conclusions:
The results of retransplantation for acute rejection and early graft failure are poor enough to suggest that this option is not advisable. However, retransplantation for CAV is currently associated with satisfactory survival and should continue to be offered to selected patients.