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Urgent heart transplantation in patients with previous sternotomies. Cardiac Transplant Team
R R Vijayanagar1, G L Chan, S S Weinstein
1Heart Transplant Service, Tampa General Hospital, FL 33606, USA.
Insights
Urgent heart transplantation for critically ill patients with prior sternotomies shows similar intermediate-term outcomes to elective procedures. Despite higher initial mortality, these patients benefit from transplantation, justifying urgent priority.
Area of Science:
- Cardiology
- Transplantation Surgery
- Critical Care Medicine
Background:
- Prior sternotomy and critical illness increase risks after heart transplantation.
- The benefit of urgent heart transplantation for these high-risk patients is debated.
Purpose of the Study:
- To evaluate outcomes of urgent versus elective heart transplantation in patients with prior sternotomies.
- To determine if critically ill patients with prior sternotomies should receive urgent transplantation.
Main Methods:
- Retrospective analysis of 64 patients with 1-4 previous sternotomies undergoing heart transplantation.
- Comparison of outcomes between critically ill patients (urgent, n=23) and stable patients (elective, n=41).
Main Results:
- Higher 30-day mortality in the urgent group (22% vs. 10%), not statistically significant.
- Similar 1-year allograft survival (72% vs. 74%) and intermediate-term complication rates between groups.
- No significant differences in coagulopathy, re-exploration, infection, renal failure, or rejection.
Conclusions:
- Critically ill patients with prior sternotomies have similar intermediate-term heart transplant outcomes to stable patients.
- Urgent heart transplantation remains a viable option for critically ill patients with prior sternotomies.
Abstract:
Critically ill patient status and prior sternotomy have separately been associated with increased risk of mortality and morbidity after heart transplantation. Consequently, the justification of assigning urgent priority for transplantation to critically ill patients with prior sternotomy may be arguable. The authors therefore undertook a retrospective analysis to evaluate the outcome of urgent and elective heart transplantation in 64 patients who had undergone one to four previous sternotomies. Patients in group 1 (n = 23) were critically ill and underwent urgent heart transplantation. Group 2 (n = 41) consisted of more stable patients who received heart transplantation as an elective procedure. Intravenous inotropes or mechanical circulatory support were required by all patients in group 1 but by none in group 2. The mortality rate within 30 days post-transplant was higher in group 1 than in group 2 (22% versus 10%), though the difference was not statistically significant. The 1-year actuarial allograft survival was similar between the two groups (72% versus 74%). In addition, there was no significant difference between groups 1 and 2 in the incidence of postoperative coagulopathy (57% versus 42%), re-exploration (13% versus 15%), early infections (57% versus 49%), renal failure (17% versus 10%) or rejection episodes in the first 3 months (65% versus 78%). The authors' findings suggest that despite higher operative mortality in critically ill patients with previous sternotomies, the intermediate-term outcome of heart transplantation in these patients is similar to that in more stable patients. Critically ill patients with prior sternotomies should therefore continue to be considered for urgent heart transplantation.