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Risk factors for death after heart transplantation: does a single-center experience correlate with multicenter
J F McCarthy1, P M McCarthy, M G Massad
1Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Ohio 44195, USA. mccartp@cesmtp.ccf.org
Insights
This single-center heart transplant study found that factors like older donor/recipient age and mechanical support are not risk factors for mortality. Significant mortality risks include early transplant era, female donor, CMV-positive donor, high pulmonary vascular resistance, and positive crossmatch.
Area of Science:
- Cardiology
- Transplantation Medicine
- Immunology
Background:
- Multicenter registries often document heart transplantation (Tx) mortality risk factors.
- These registry findings may not accurately reflect outcomes at individual centers.
- This study aimed to analyze single-center heart Tx outcomes and compare them to registry data.
Purpose of the Study:
- To evaluate pre-transplant factors influencing mortality in a single-center heart transplantation experience.
- To compare these identified risk factors with those reported in multicenter registry studies.
Main Methods:
- A retrospective review of 405 adult primary heart Tx recipients from January 1984 to December 1995.
- Analysis of factors including demographics, Tx era, cytomegalovirus (CMV) status, donor/recipient age, pulmonary hypertension, mechanical support, ischemia time, and crossmatch results.
Main Results:
- One- and 5-year survival rates were 87.8% and 73.4%, respectively.
- Contrary to registry data, reoperative procedures, left ventricular assist device (LVAD) support, older donor/recipient age, and ischemia time up to 4.2 hours were not significant risk factors.
- Significant mortality risk factors identified: early transplant era (1984-1989), female donor, CMV-seropositive donor, high pulmonary vascular resistance, and intra-aortic balloon pump (IABP) support. Positive B-cell flow cytometry crossmatch was a risk factor in univariate analysis.
Conclusions:
- Identified a recipient group, considered high-risk in multicenter registries, who are not at increased mortality risk at this center.
- Supports expanded use of older donors/recipients and bridged transplants, potentially increasing the donor pool.
- Prognostic factors identified can facilitate more liberal patient and donor selection for heart transplantation.
Background:
Risk factors for death after heart transplantation (Tx) are frequently documented from multicenter registries. Although this information is helpful, it reflects a whole range of experiences and results, and may not translate to a particular center. This study was performed to (1) evaluate pre-Tx factors affecting mortality in a single-center experience, and (2) compare these factors with risk factors obtained from multicenter registry reports.
Methods:
Review of our transplant database between January 1984 and December 1995 identified 405 adults who received a primary heart Tx. Multiple factors were analyzed, including demographics, Tx era, cytomegalovirus status, United Network for Organ Sharing status of recipient, presence of pulmonary hypertension, previous cardiac operations, mechanical ventilation or circulatory support, ischemia time, number of rejection episodes, and preoperative flow cytometry crossmatching.
Results:
One- and 5-year survival rates were 87.8% and 73.4%, respectively (Kaplan-Meier). Contrary to multicenter registry reports, our data indicate that reoperative procedures, left ventricular assist device support, increasing donor and recipient age, and ischemia time up to 4.2 hours are not risk factors for death after Tx. Likewise, mode of donor death is not a risk factor affecting outcome. Significant risk factors for mortality identified by multivariate analysis included early transplant era (1984 to 1989; p = 0.002), female donor (p = 0.042), cytomegalovirus-seropositive donor (p = 0.048), high pulmonary vascular resistance (p = 0.018), and intraaortic balloon pump support (p = 0.03). It also identified a positive B-cell flow cytometry crossmatch (p = 0.015) to be a risk factor with univariate analysis.
Conclusions:
Our data identify a group of recipients, reportedly at high risk in multicenter registries, who are not at increased risk of death after Tx. This information supports the growing experience with older donors and recipients and with bridged transplants, and has allowed us to expand our donor pool. These prognostic factors at evaluation allow more liberal selection of patients and donors for transplantation.