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Outcomes in patients undergoing cardiac retransplantation: A propensity matched cohort analysis of the UNOS Registry
Robert J H Miller1, Brian A Clarke2, Jonathan G Howlett2
1Section of Heart Failure, Cardiac Transplant, and Mechanical Circulatory Support, and Department of Medicine, Stanford University, Stanford, California, USA; Division of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada.
Insights
Late cardiac retransplantation, performed more than a year after the initial procedure and not for acute rejection, does not increase mortality risk. However, early retransplantation or retransplantation for acute rejection remains associated with higher mortality in heart transplant recipients.
Area of Science:
- Cardiology
- Transplantation Medicine
- Immunology
Background:
- Cardiac retransplantation, comprising 3% of heart transplants, is linked to increased mortality.
- Factors like prior sternotomy, patient sensitization, and renal dysfunction may contribute to higher mortality in retransplant patients.
- This study investigates if retransplantation itself is a mortality risk factor after accounting for patient-specific risk factors.
Purpose of the Study:
- To determine if cardiac retransplantation is associated with increased all-cause mortality.
- To differentiate mortality risks between early (<1 year) and late (>1 year) retransplantation.
- To assess the impact of retransplantation indication (e.g., acute rejection) on outcomes.
Main Methods:
- Retrospective cohort study using the United Network for Organ Sharing database.
- Identified adult and pediatric patients undergoing cardiac retransplantation.
- Utilized propensity-score matching to compare retransplant recipients with initial heart transplant recipients.
Main Results:
- Of 62,112 heart transplant recipients, 2,202 (3.4%) underwent late retransplantation.
- Late retransplantation (>1 year, not for acute rejection) showed comparable 1-year all-cause mortality rates (13.6% vs 13.8%) to initial transplants.
- Early retransplantation (<1 year) or for acute rejection significantly increased post-transplant mortality risk (HR 1.79).
Conclusions:
- Late cardiac retransplantation in adults is not associated with increased all-cause mortality after adjusting for comorbidities.
- The timing of retransplantation and the reason for it are critical factors influencing patient outcomes.
- Careful assessment of indication acuity and comorbid conditions is crucial when evaluating candidacy for cardiac retransplantation.
Background:
Cardiac retransplantation accounts for approximately 3% of cardiac transplantation and is considered a risk factor for increased mortality. However, factors inherent to retransplantation including previous sternotomy, sensitization, and renal dysfunction may account for the increased mortality. We assessed whether retransplantation was associated with all-cause mortality after adjusting for such patient risk factors.
Methods:
We conducted a retrospective cohort study of adult and pediatric patients enrolled in the United Network for Organ Sharing database. We identified patients undergoing cardiac retransplantation based on transplant listing diagnosis and history of previous transplant. We used propensity-score matching to identify a matched cohort undergoing initial heart transplantation.
Results:
In total, 62,112 heart transplant recipients were identified, with a mean age 46.6 ± 19.1 years. Of these, 2,202 (3.4%) underwent late cardiac retransplantation (>1 year after initial transplant and not for acute rejection). Compared with a matched group of patients undergoing initial heart transplantation, patients undergoing late retransplantation had comparable rates of all-cause mortality at 1 year (13.6% vs 13.8%, p = 0.733). In addition, overall mortality was not significantly different after matching (unadjusted hazard ratio [HR] 1.08, p = 0.084). In contrast, patients undergoing retransplantation within 1 year of initial transplant or for acute rejection remained at increased risk of mortality post-transplant after similar matching (unadjusted HR 1.79, p < 0.001).
Conclusions:
After matching for comorbidities, late retransplantation in the adult population was not associated with an increase in all-cause mortality. Our findings highlight the importance of assessing indication acuity and comorbid conditions when considering retransplant candidacy.
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