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Heart transplantation with and without prior sternotomy: analysis of the United Network for Organ Sharing database
1Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California, USA.
Insights
Prior sternotomy increases early mortality and morbidity after heart transplantation but does not affect long-term survival. This finding is crucial for risk assessment in heart transplant candidates.
Area of Science:
- Cardiology
- Transplantation Medicine
- Surgical Outcomes Research
Background:
- Prior sternotomy in heart transplant recipients is associated with potentially poorer outcomes.
- Quantifying the specific risks associated with prior sternotomy remains an area needing further establishment.
Purpose of the Study:
- To assess early and late survival rates in adult heart transplant recipients with and without a history of prior sternotomy.
- To identify predictors of outcomes, specifically focusing on the impact of prior sternotomy.
Main Methods:
- Analysis of the United Network for Organ Sharing (UNOS) database for adult heart-only transplant recipients from 1997 to 2011.
- Division of 11,266 recipients into a 'first sternotomy' group (n=6006) and a 'redo sternotomy' group (n=5260).
- Utilized a multivariable Cox proportional hazards model to identify mortality predictors.
Main Results:
- The redo sternotomy group experienced significantly lower 60-day survival (92.6% vs 95.9%; HR 1.83).
- Redo sternotomy was linked to increased early post-transplant complications: cardiac reoperations (12.3% vs 8.8%), dialysis (8.9% vs 5.2%), infections (23.2% vs 19%), and strokes (2.5% vs 1.4%).
- Prior sternotomy independently predicted mortality, alongside other factors like age, gender, and pre-transplant organ function.
Conclusions:
- Prior sternotomy is associated with a 3.3% excess mortality and increased morbidity within 60 days post-heart transplantation.
- Conditional 5-year survival after the initial 60-day period is not adversely affected by a history of prior sternotomy.
- Findings necessitate consideration of prior sternotomy in risk stratification models for heart transplant candidates.
Introduction:
Patients with history of prior sternotomy may have poorer outcomes after heart transplantation. Quantitation of risk from prior sternotomy has not been well established. The United Network for Organ Sharing (UNOS) database was analyzed to assess early and late survival and predictors of outcome in adult heart transplant recipients with and without prior sternotomy.
Methods:
Of 11,266 adults with first heart-only transplantation from 1997 to 2011, recipients were divided into 2 groups: those without prior sternotomy (first sternotomy group; n = 6006 or 53.3%) and those with at least 1 prior sternotomy (redo sternotomy group; n = 5260 or 46.7%). A multivariable Cox model was used to identify predictors of mortality.
Results:
Survival was lower in the redo group at 60 days (92.6% vs 95.9%; hazard ratio [HR] 1.83, 95% confidence interval [CI]: 1.56-2.15; P < .001). Conditional 5-year survival in 60-day survivors was similar in the 2 groups (HR = 1.01, 95% CI 0.90-1.12, P = .90). During the first 60 days post-transplant, the redo group had more cardiac reoperations (12.3% vs 8.8%, P = .0008), a higher frequency of dialysis (8.9% vs 5.2%, P < .0001), a greater percentage of drug-treated infections (23.2% vs 19%, P = .003), and a higher percentage of strokes (2.5% vs 1.4%, P = .0001). A multivariable Cox proportional hazards model identified prior sternotomy as a significant independent predictor of mortality, in addition to age, female gender, congenital cardiomyopathy, need for ventilation, mechanical circulatory support, dialysis prior to transplant, pretransplant serum bilirubin (≥ 3 mg/dL), and preoperative serum creatinine (≥ 2 mg/dL).
Conclusions:
Prior sternotomy is associated with an excess 3.3% mortality and higher morbidity within the first 60 days after heart transplantation, as measured by frequency of dialysis, drug-treated infections, and strokes. Conditional 5-year survival after 60 days is unaffected by prior sternotomy. These findings should be taken into account for risk assessment of patients undergoing heart transplantation.
