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Cardiac transplantation: the Stanford experience in the cyclosporine era
G E Sarris1, K A Moore, J S Schroeder
1Department of Cardiothoracic Surgery, Stanford University School of Medicine, CA 94305.
Insights
This study on 496 heart transplant patients found that higher pulmonary vascular resistance and female gender predicted hospital death. Long-term survival rates were 41% at 10 years, with rejection, infection, and graft coronary disease being major causes of mortality.
Area of Science:
- Cardiology
- Immunosuppression
- Transplantation Medicine
Background:
- Cyclosporine immunosuppression has been a cornerstone of cardiac transplantation since 1980.
- Understanding long-term outcomes and predictors of mortality is crucial for improving patient survival.
Purpose of the Study:
- To analyze the outcomes of 496 primary cardiac transplantations performed between 1980 and 1993.
- To identify independent predictors of hospital mortality after heart transplantation.
- To evaluate long-term survival rates and causes of death, including rejection, infection, and graft coronary disease.
Main Methods:
- Retrospective analysis of 496 primary cardiac transplant recipients.
- Multivariate logistic regression to identify predictors of hospital death.
- Actuarial survival and freedom from adverse events (rejection, infection, graft coronary disease) were calculated.
Main Results:
- Operative mortality was 7.9%. Higher pulmonary vascular resistance and female gender were independent predictors of hospital death.
- Ten-year survival was 41%. Major causes of death included infection (34%), graft coronary disease (18%), and rejection (14%).
- Freedom from rejection at 5 years was 7.2%, from any infection at 5 years was 15%, and from graft coronary artery disease at 10 years was 65%.
Conclusions:
- Pulmonary vascular resistance and female gender are significant predictors of early mortality in cardiac transplant recipients.
- Long-term survival remains a challenge, with infection, graft coronary disease, and rejection being leading causes of graft loss and death.
- Further strategies are needed to mitigate these long-term complications and improve outcomes in heart transplantation.
Abstract:
We analyzed our experience with 496 patients who underwent primary cardiac transplantation since the introduction of cyclosporine immunosuppression (Dec. 16, 1980, to Jan. 7, 1993). There were 388 male and 108 female patients. Mean recipient age was 40 +/- 16 years (range 0.1 to 70 years, median 44 years). Recipient diagnoses included coronary disease in 188, idiopathic cardiomyopathy in 196, viral cardiomyopathy in 35, and congenital heart disease in 28 patients. Donor age was 25 +/- 10 years (range 1 to 53 years, median 24 years). Graft ischemic time was 148 +/- 57 minutes (range 38 to 495 minutes, median 149 minutes). Operative mortality (hospital death) rate was 7.9% +/- 1.3% (70% confidence intervals). Multivariate logistic regression analysis revealed that (higher) pulmonary vascular resistance and gender (female) were the only independent predictors of hospital death (p < 0.05). Actuarial survival estimates for all patients at 1, 5, and 10 years are 82% +/- 1.7% (83% +/- 1.8% adult, 77% +/- 5.2% pediatric), 61% +/- 2.5% (65% +/- 2.5% adult, 64% +/- 6.6% pediatric), and 41% +/- 3.7% (40% +/- 4% adult, 54% +/- 8.6% pediatric), respectively. For 232 patients treated with triple-drug immunosuppression and induction with OKT3 since 1987, survival estimates at 1 and 5 years are 82% +/- 2.6% and 67% +/- 3.7%, respectively. Causes of death for the entire group were rejection in 29 (14% of deaths), infection in 69 (34%), graft coronary disease in 36 (18%), nonspecific graft failure in 6 (3%), malignancy in 19 (10%), stroke in 6 (3%), pulmonary hypertension in 6 (3%), and other causes in 30 (15%) patients. Actuarial freedom from rejection at 3 months, 1 year, and 5 years was 21% +/- 1.9%, 14% +/- 1.7%, and 7.2% +/- 1.5%, respectively (+/- 1 standard error of the mean). Estimates of freedom from rejection-related death at 1, 5, and 10 years were 96% +/- 1%, 93% +/- 1.4%, and 93% +/- 1.4%, respectively. Actuarial freedom from any infection at 3 months and at 1 and 5 years was 40% +/- 2.3%, 27% +/- 2.1%, and 15% +/- 2.0% and from infection-related death, 95% +/- 1.0%, 93% +/- 1.2%, and 85% +/- 1.9%, respectively. Actuarial freedom from (angiographic or autopsy proved) graft coronary artery disease at 1, 5, and 10 years was 95% +/- 1.2%, 73% +/- 2.7%, and 65% +/- 3.6% and from coronary disease-related death or retransplantation 98% +/- 0.7%, 84% +/- 2.2%, and 66% +/- 4.3%, respectively.(ABSTRACT TRUNCATED AT 400 WORDS)