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A High-Fidelity Porcine Model of Orthotopic Heart Transplantation Following Donation after Circulatory Death
Published on: June 6, 2025
Who is the high-risk recipient? Predicting mortality after heart transplant using pretransplant donor and recipient
Kimberly N Hong1, Alexander Iribarne, Berhane Worku
1Division of Cardiothoracic Surgery, Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, New York, USA.
Insights
A new risk stratification score (RSS) helps predict 1-year graft failure after heart transplantation. This score identifies patients at high risk, improving organ allocation and patient outcomes.
Area of Science:
- Cardiology
- Transplantation Medicine
- Medical Statistics
Background:
- Pretransplant recipient and donor characteristics significantly impact heart transplant outcomes.
- Objective assessment of these factors is crucial for predicting graft survival.
- Developing a reliable risk score can aid in clinical decision-making.
Purpose of the Study:
- To objectively assess risks associated with pretransplant characteristics in heart transplant recipients.
- To develop a preoperative risk stratification score (RSS) for predicting 1-year graft loss.
- To define distinct risk strata based on the developed RSS.
Main Methods:
- Analysis of 11,703 heart transplant recipients from the United Network for Organ Sharing (2001-2007).
- Multivariable logistic regression to identify predictors of 1-year graft failure.
- Development of an RSS using odds ratios and defining strata via receiver operating characteristic curves.
Main Results:
- Key predictors of graft failure include prior mechanical support (RVAD, ECMO, LVAD, TAH), renal failure, and advanced age.
- Five RSS strata were identified: Low (27.7%), Intermediate (54.2%), Moderate (13.2%), Elevated (2.6%), and High Risk (2.2%).
- 1-year survival rates decreased significantly with increasing RSS strata, from 93.8% (Low) to 47.0% (High).
Conclusions:
- Pretransplant recipient factors are significant predictors of early and late graft failure.
- The developed RSS can enhance organ allocation strategies.
- Utilizing the RSS may mitigate negative outcomes in high-risk heart transplant candidates.
Background:
In this study we sought the following: (1) To objectively assess the risk related to various pretransplant recipient and donor characteristics; (2) to devise a preoperative risk stratification score (RSS) based on pretransplant recipient and donor characteristics predicting graft loss at 1 year; and (3) to define different risk strata based on RSS.
Methods:
The United Network for Organ Sharing provided de-identified patient-level data. Analysis included 11,703 orthotopic heart transplant recipients aged 18 years or greater and transplanted between January 1, 2001 and December 31, 2007. The primary outcome was 1-year graft failure. Multivariable logistic regression analysis (backward p value<0.20) was used to determine the relationship between pretransplant characteristics and 1-year graft failure. Using the odds ratio for each identified variable, an RSS was devised. The RSS strata were defined by calculating receiver operating characteristic curves and stratum specific likelihood ratios.
Results:
The strongest negative predictors of 1-year graft failure included the following: right ventricular assist device only, extracorporeal membrane oxygenation, renal failure, extracorporeal left ventricular assist device, total artificial heart, and advanced age. Threshold analysis identified 5 discrete RSS strata: low risk (LR, RSS: <2.55; n=3242, 27.7%), intermediate risk (IR, RSS: 2.55-5.72; n=6,347, 54.2%), moderate risk (MR, RSS: 5.73-8.13; n=1,543, 13.2%), elevated risk (ER, RSS: 8.14-9.48; n=310, 2.6%), and high risk (HR, RSS: >9.48; n=261, 2.2%). The 1-year actuarial survival (%) in the LR, IR, MR, ER, and HR groups were 93.8, 89.2, 81.3, 67.0, and 47.0, respectively.
Conclusions:
Pretransplant recipient variables significantly influence early and late graft failure after heart transplantation. The RSS may improve organ allocation strategies by reducing the potential negative impact of transplanting candidates who are at a high risk for poor postoperative outcomes.
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