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Clinical experience with cardiac retransplantation
R E Michler1, M J McLaughlin, J M Chen
1Division of Cardiothoracic Surgery, Columbia-Presbyterian Medical Center, Columbia University College of Physicians & Surgeons, New York, NY.
Insights
Cardiac retransplantation shows promising survival rates comparable to primary heart transplants. Early graft failure does not impact long-term outcomes, suggesting retransplantation is a viable option for select patients.
Area of Science:
- Cardiology
- Transplantation Medicine
- Immunology
Background:
- Cardiac retransplantation is an option for end-stage heart failure, yet data on its outcomes and selection criteria remain limited.
- Over 560 cardiac retransplantations have been performed globally, but few studies have analyzed this patient population.
- This study evaluates the risks and outcomes associated with cardiac retransplantation.
Purpose of the Study:
- To assess the outcomes of cardiac retransplantation.
- To compare survival rates between primary heart transplant recipients and those undergoing retransplantation.
- To identify factors influencing the success of cardiac retransplantation.
Main Methods:
- Retrospective review of cardiac retransplantation cases at Columbia-Presbyterian Medical Center between February 1977 and March 1991.
- Analysis of 14 retransplantation procedures among 408 patients who received primary transplants during the cyclosporine era.
- Comparison of survival, rejection rates, and mortality between primary transplant and retransplant cohorts.
Main Results:
- Actuarial survival rates at 1 and 2 years were similar for primary transplant recipients (75.1%, 71.3%) and retransplant patients (71.4%, 59.5%).
- No significant differences were observed in rejection rates or early mortality (<30 days) between the two groups.
- Indications for retransplantation included transplant coronary artery disease (8 cases), rejection (5 cases), and graft failure (1 case).
Conclusions:
- Cardiac retransplantation offers a good prognosis, particularly when indicated more than 30 days after the initial transplant.
- Survival outcomes and rejection rates for retransplantation are comparable to primary heart transplantation.
- Further research is needed to refine selection criteria for cardiac retransplantation.
Abstract:
Although more than 560 patients worldwide have undergone cardiac retransplantation, few studies of this population have been reported. To evaluate the risk of cardiac retransplantation and to better establish selection criteria, we reviewed the records of all patients who underwent retransplantation at the Columbia-Presbyterian Medical Center. Of 431 patients who underwent transplantation between February 1977 and March 1991, 408 underwent the procedure in the era of cyclosporine-based immunosuppression. Thirteen of these 408 patients underwent retransplantation (including one patient who received a third graft). Indications for the 14 retransplantations included transplant coronary artery disease (n = 8), rejection (n = 5), and intraoperative graft failure (n = 1). Immunosuppression and follow-up protocols used in this cohort were similar to those in the primary transplantation population. No significant differences were found in either actuarial survival between primary transplant recipients (75.1% +/- 2.2% at 1 year and 71.3% +/- 2.4% at 2 years) and patients who underwent retransplantation (71.4% +/- 12.1% at 1 year and 59.5% +/- 14.8% at 2 years) or in linearized rates of rejection and actuarial freedom from rejection between the two groups. No differences between these groups were found with regard to age, sex, race, origin of end-stage heart disease, or early (< 30 day) mortality. The origin of primary graft failure did not correlate with survival outcome in the retransplantation cohort. Follow-up time for patients having primary transplantation ranged from 0 to 8 years (mean 24 months) with a cumulative patient follow-up of 830 patient-years; follow-up time for patients who underwent retransplantation ranged from 0 to 3 years (mean 8.1 months) with a cumulative patient follow-up of 9.5 patient-years. Approximately 50% of patients in both groups had at least one rejection episode by 3 months. Within the limited time period studied after retransplantation, only one patient had transplant coronary artery disease, approximately 27 months after her first retransplantation procedure for acute rejection. These results indicate that the prognosis for patients undergoing cardiac retransplantation is good for patients for whom the indication for retransplantation is identified more than 30 days after initial transplantation.