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Pretransplantation risk factors for death after heart transplantation: a multiinstitutional study. The Transplant
R C Bourge1, D C Naftel, M R Costanzo-Nordin
1Transplant Cardiologists Research Database Center, University of Alabama, Birmingham 35294.
Insights
This study identified key risk factors for death after heart transplantation, including recipient/donor age, graft failure, and infection. Understanding these factors can improve patient selection and transplant outcomes.
Area of Science:
- Cardiology
- Transplantation Medicine
- Immunology
Background:
- Heart transplantation is a life-saving procedure for end-stage heart failure.
- Identifying risk factors for mortality is crucial for improving patient outcomes.
- Previous studies have highlighted various factors, but a comprehensive analysis of early-term risk factors is needed.
Purpose of the Study:
- To identify significant risk factors associated with death in the early period after primary heart transplantation.
- To analyze multi-institutional data to provide a robust understanding of these risk factors.
- To inform strategies for improved patient and donor selection in heart transplantation.
Main Methods:
- Analysis of a large cohort (n=911) from 25 institutions, covering primary heart transplantations from January 1990 to June 1991.
- Utilized multivariable analysis to determine the statistical significance of various potential risk factors.
- Examined causes of death, including infection and graft failure, and their correlation with patient and donor characteristics.
Main Results:
- Overall survival rates were 93% at 1 month and 84% at 12 months.
- Leading causes of death were infection (45%) and early graft failure.
- Identified risk factors included very young or advanced recipient age, ventilator support, abnormal renal function, lower cardiac output, higher pulmonary vascular resistance (in children), longer donor ischemic time, older donor age, and ABO blood type incompatibility.
Conclusions:
- Recipient age (very young or advanced), donor factors (ischemic time, age), and physiological status (ventilator support, renal function) significantly impact early mortality after heart transplantation.
- ABO blood type incompatibility and early graft failure are critical concerns.
- These findings can guide improved patient/donor selection and direct future research to enhance heart transplant safety and efficacy.
Abstract:
Risk factors for death after heart transplantation were identified by analyzing the total primary heart transplantation experience (n = 911) among 25 institutions from January 1, 1990, through June 30, 1991. Overall actuarial survival was 93% at 1 month and 84% at 12 months. The hazard function for death was highest early after heart transplantation and fell rapidly over the first 6 months, with a gradually declining hazard thereafter. The two most common causes of death were infection (n = 29) and early graft failure (n = 28), accounting for 45% of the overall deaths. By multivariable analysis, risk factors for death during the study period included very young recipient age (p = 0.004), advanced age (p = 0.009), ventilator support at time of transplantation (p = 0.09), abnormal renal function (p = 0.1), lower pretransplantation cardiac output (p = 0.009), higher pulmonary vascular resistance in children (p = 0.006), longer donor ischemic time (p = 0.001), older donor age (p = 0.001), and donor and recipient not both blood type O (p = 0.009). The recipient age effect was greatest in patients under 5 years of age (1-year survival rate 68% versus 85% for all others, p = 0.002). Patients aged 60 years and older had a 1-year survival rate of 81%. Patients who were ventilator dependent at transplantation fared especially poorly, with a 3-month survival rate of 65%. Transplantation of a blood group O heart into a non-O recipient had a somewhat lower 1-year survival rate than did blood group O into an O recipient (82% versus 88%, p = 0.06). The adverse effect of a longer ischemic time was most notable after 4 hours (1-month survival rate 71% for more than 4 hours versus 85% for less than 4 hours, p = 0.0003). Inference: These multiinstitutional-derived risk factors for early-term death after heart transplantation may help improve patient and donor selection and focus further scientific investigations to increase the safety of heart transplantation.