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Heart transplantation in patients with previous cardiac operations. Excellent clinical results
G Y Ott1, D J Norman, J D Hosenpud
1Oregon Cardiac Transplant Program, Oregon Health Sciences University, Portland.
Insights
Heart transplantation outcomes are similar for patients with and without prior cardiac surgery. However, repeat heart transplants pose a significantly higher risk, emphasizing careful patient selection for improved survival.
Area of Science:
- Cardiology
- Transplantation Surgery
- Medical Research
Background:
- Many heart transplant candidates have prior cardiac surgery, potentially increasing reoperation risks.
- Previous cardiac operations can introduce technical complexities and other factors affecting transplant outcomes.
Purpose of the Study:
- To compare the outcomes of orthotopic heart transplantation in patients with and without prior cardiac operations.
- To identify specific patient subsets at higher risk for adverse outcomes following heart transplantation.
Main Methods:
- A retrospective analysis of 155 orthotopic heart transplantations performed between December 1985 and June 1991.
- Patients were divided into two groups: initial cardiac operation (Group I) and previous non-transplant cardiac operations (Group II).
- Comparison of preoperative variables, operative data, operative mortality, and actuarial survival rates between the groups.
Main Results:
- Group II patients were older and had a higher prevalence of ischemic heart disease compared to Group I.
- Group II experienced significantly longer cardiopulmonary bypass and operation times.
- Operative mortality and 1-year and 5-year actuarial survival rates were similar between Group I (4.7% mortality, 87.1%/72.9% survival) and Group II (6.6% mortality, 85.3%/76.0% survival).
- Patients undergoing a second cardiac transplantation (n=9) showed significantly higher operative mortality (22.8%) and lower 1-year survival (33.3%).
Conclusions:
- Orthotopic heart transplantation can be performed in patients with prior non-transplant cardiac operations without compromising immediate or long-term survival.
- Second cardiac transplantation represents a high-risk subset requiring careful consideration.
- Prior cardiac surgery does not appear to be an independent predictor of poor outcome in heart transplantation, excluding repeat transplants.
Abstract:
A significant proportion of potential transplant recipients have undergone previous cardiac procedures and may be subject to an increased risk because of technical and other factors inherent in a reoperation. Between December 1985 and June 1991, 155 orthotopic heart transplantations were carried out in 146 patients. Eighty-five transplantations (54.8%) were carried out as the initial cardiac operation (group I); 61 operations (45.2%) were performed in patients who had previous nontransplant cardiac operations (group II). Preoperative variables including hemodynamic indexes, renal function, and status on the waiting list were similar between these groups; however, group II patients tended to be older than group I patients (51.9 +/- 10.7 versus 47.7 +/- 11.6 years, respectively; p < 0.05) and were more likely to have ischemic heart disease (80.3% versus 34.1%) than were those in group I. Significantly longer cardiopulmonary bypass time (127.6 +/- 44.7 minutes versus 108.2 +/- 18.8 minutes, p < 0.01) and duration of operation (448.1 +/- 120.9 minutes versus 353.2 +/- 85.1 minutes, p < 0.01) was found in group II. Operative mortality in group I was 4.7% and in group II was 6.6% (p > 0.9). Group I actuarial survival at 1 year and 5 years was 87.1% +/- 3.6% and 72.9% +/- 6.2%, respectively. Group II actuarial survival was 85.3% +/- 4.5% and 76.0% +/- 6.6%, respectively, for the same time periods. In spite of the greater technical challenge implied by previous cardiac operations, no significant survival differences occurred between these groups (p > 0.9). However, patients undergoing a second cardiac transplantation (n = 9) were identified as a high-risk subset with operative mortality of 22.8% and 1-year survival of only 33.3% +/- 15.7% (p < 0.0003). Cardiac transplantation in patients who have undergone previous nontransplant cardiac operations can be carried out without compromising immediate or long-term outcome.