Should we perform heart retransplantation in early graft failure? (original) (raw)
Related papers
European Journal of Cardio-Thoracic Surgery, 2008
Objective: Survival after heart transplantation has improved significantly over the last decades. There are a growing number of patients that require cardiac retransplantation because of chronic allograft dysfunction. With regard to the critical shortage of cardiac allograft donors the decision to offer repeat heart transplantation must be carefully considered. Methods: Since 1983 a total of 807 heart transplantations have been performed at our institution. Among them 41 patients received cardiac retransplantation, 18 patients because of acute graft failure and 23 because of chronic graft failure. Data were analyzed for demographics, morbidity and risk factors for mortality. The acute and chronic retransplant group was compared to those patients undergoing primary transplantation. Results: The mean interval between primary transplantation and retransplantation was 1.9 days in the acute and 6.7 years in the chronic retransplant group. Mean follow-up was 6.9 years. Baseline characteristics were similar in the primary and retransplant group. Actuarial survival rates at 1, 3, 5 and 7 years after primary cardiac transplantation compared to retransplantation were 83, 78, 72 and 64% vs 53, 50, 47 and 36%, respectively (p < 0.001). Early mortality after acute retransplantation was significantly higher compared to late retransplantation (10/18, 55.6% vs 4/23, 17.4%, p = 0.011). Major causes of death were acute and chronic rejection, infection and sepsis. Conclusions: Cardiac retransplantation is associated with lower survival rates compared to primary transplantation. However, results after retransplantation in chronic graft failure are significantly better compared to acute graft failure. Therefore, we consider cardiac retransplantation in chronic graft failure a justified therapeutic option. In contrast, patients with acute graft failure seem to be inappropriate candidates for cardiac retransplantation.
Heart Retransplantation: A 23-Year Single-Center Clinical Experience
The Annals of Thoracic Surgery, 1998
Background. The main causes of allograft failure after cardiac transplantation are primary graft dysfunction, intractable acute rejection, and coronary graft disease. Despite the important progress in the last several years in graft preservation, surgical techniques, immunosuppression, and treatment of coronary graft disease, retransplantation in selected cases is the only way to achieve long-term recipient survival.
Long-term experiences on cardiac retransplantation in adults
European Journal of Cardio-Thoracic Surgery, 2007
Background: It remains disputed whether cardiac retransplantation should be performed. This study aimed to evaluate our long-term experiences on cardiac retransplantation in adults. Patients and methods: Between March 1989 and December 2004, 2% (28/1290) of cardiac retransplantations were performed. Results: The reasons for cardiac retransplantation were cardiac allograft vasculopathy (n = 13; 47%), primary graft failure (n = 11; 39%), and refractory acute rejection (n = 4; 14%). The 30-day mortality risk was 29% (acute rejection: 50%; primary graft failure: 36%; cardiac allograft vasculopathy: 15%, p = 0.324), compared to 8.5% for primary cardiac transplantation ( p < 0.001). The causes of early death were acute rejection (n = 3; 37%), multiorgan failure (n = 3; 37%), primary graft failure (n = 1; 13%), and right ventricular failure (n = 1; 13%). The late mortality rate was 96/1000 patient-years. The causes of late death were acute rejection (n = 4; 50%), cardiac allograft vasculopathy (n = 2; 25%), multiorgan failure (n = 1; 13%), and infection (n = 1; 13%). The 1-, 5-, 10-, and 15-year survival was respectively 78, 68, 54, and 38% (primary cardiac transplantation), and 46, 41, 32, and 32% (cardiac retransplantation) ( p = 0.003). The short-term survival for cardiac retransplantation due to cardiac allograft vasculopathy was likely better than primary graft failure and refractory acute rejection ( p = 0.09). Conclusion: The overall outcomes of cardiac retransplantation are significantly inferior to primary cardiac transplantation. Cardiac retransplantation should be only performed for selected patients. #
Can cardiac re-transplantation be performed with an acceptable survival after primary graft failure?
Interactive cardiovascular and thoracic surgery, 2005
A best evidence topic in cardio thoracic surgery was written according to a structured protocol. The question addressed whether cardiac re-transplantation can be performed with an acceptable survival in patients who suffer primary graft failure? Altogether 458 papers were found using the reported search, of which 18 presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. We conclude that while re-transplantation for graft coronary disease has a similar survival to patients undergoing primary transplantation, acute graft failure or rejection should be treated with a mechanical assist device, as acute re-transplantation is associated with an unacceptably high mortality.
Early and late outcomes after cardiac retransplantation
Canadian Journal of Surgery, 2013
Background: Cardiac retransplantation remains the most viable option for patients with allograft heart failure; however, careful patient selection is paramount considering limited allograft resources. We analyzed clinical outcomes following retransplantation in an academic, tertiary care institution. Methods: Between 1981 and 2011, 593 heart transplantations, including 22 retransplantations were performed at our institution. We analyzed the preoperative demographic characteristics, cause of allograft loss, short-and long-term surgical outcomes and cause of death among patients who had cardiac retransplantations. Results: Twenty-two patients underwent retransplantation: 10 for graft vascular disease, 7 for acute rejection and 5 for primary graft failure. Mean age at retransplantation was 43 (standard deviation [SD] 15) years; 6 patients were women. Thirteen patients were critically ill preoperatively, requiring inotropes and/or mechanical support. The median interval between primary and retransplantation was 2.2 (range 0-16) years. Thirty-day mortality was 31.8%, and conditional (> 30 d) 1-, 5-and 10-year survival after retransplantation were 93%, 79% and 59%, respectively. A diagnosis of allograft vasculopathy (p = 0.008) and an interval between primary and retransplantation greater than 1 year (p = 0.016) had a significantly favourable impact on 30-day mortality. The median and mean survival after retransplantation were 3.3 and 5 (SD 6, range 0-18) years, respectively; graft vascular disease and multiorgan failure were the most common causes of death. Conclusion: Long-term outcomes for primary and retransplantation are similar if patients survive the 30-day postoperative period. Retransplantation within 1 year of the primary transplantation resulted in a high perioperative mortality and thus may be a contraindication to retransplantation. Contexte : Une nouvelle transplantation cardiaque demeure l'option la plus viable pour les patients qui présentent une insuffisance de leur coeur transplanté. Il est toutefois crucial de bien sélectionner les patients, compte tenu du nombre limité d'organes disponibles. Nous avons analysé les résultats cliniques des secondes transplantations cardiaques dans un établissement universitaire de soins tertiaires. Méthodes : Entre 1981 et 2011, on a procédé dans notre établissement à 593 transplantations cardiaques, dont 22 secondes transplantations. Nous avons analysé les carac téristiques démographiques préopératoires, la cause de la perte du coeur transplanté, les résultats chirurgicaux à court et à long terme et la cause de mortalité chez les patients soumis à une seconde transplantation. Résultats : Vingt-deux patients ont subi une seconde greffe : 10 pour une maladie vasculaire affectant le coeur transplanté, 7 pour un rejet aigu et 5 pour une insuffisance primaire du greffon. L'âge moyen au moment de la seconde intervention était de 43 ans (écart-type [ET] 15 ans); 6 patients étaient des femmes. Treize patients étaient gravement malades avant l'intervention et avaient besoin d'inotropes et(ou) d'un soutien mécanique. L'intervalle médian entre les 2 interventions a été de 2,2 (étendue 0-16) ans. La mortalité à 30 jours s'est élevée à 31,8 % et la survie conditionnelle (> 30 jours) 1, 5 et 10 ans après la seconde transplantation a été de 93 %, 79 % et 59 %, respectivement. Un diagnostic de vasculopathie du coeur transplanté (p = 0,008) et un intervalle de plus d'un an séparant les 2 transplantations (p = 0,016) ont exercé un impact significativement favorable sur la mortalité à 30 jours. La survie médiane et la survie moyenne après la seconde transplantation ont été de 3,3 ans et de 5 ans (ET 6 ans, étendue 0-18 ans), respectivement; la maladie vasculaire du greffon et l'insuffisance pluriorganique ont été les plus fréquentes causes de mortalité. Conclusion : Les résultats à long terme des premières et secondes transplantations sont similaires si les patients survivent au-delà de la période postopératoire de 30 jours. La seconde transplantation effectuée dans l'année suivant la première a donné lieu à une mortalité périopératoire élevée et pourrait être une contre-indication à une seconde transplantation.
Is third-time heart retransplantation justifiable?
Transplantation proceedings, 2006
Since repeat heart transplantation traditionally carries higher risk than primary engraftment, we tested the hypothesis that third-time cardiac allograft transplantation is associated with prohibitive mortality and morbidity. The cohort of all third-time cardiac retransplants performed at our institution (n ϭ 3) and reported to UNOS from 1987 to 2002 (n ϭ 10) was reviewed. The primary endpoints were early and late mortality. Extending the study frame through 2003 captures a total of 5 and 15 third-time heart transplant recipients in UCLA and UNOS databases, respectively. Of the 15 patients undergoing third-time retransplants, preoperatively one was ventricular assist device-dependent, four were on intravenous inotropes, and two had creatinine levels greater than 2.5. Additionally, four were male recipients of female donor hearts and the mean donor ischemic time was 2.6 hours. One patient was diagnosed with acute allograft rejection, 13 with coronary artery vasculopathy/chronic rejection, and one with primary graft failure. At our institution, five patients underwent a third heart transplant. There was no early or hospital mortality. One patient died late from transplant coronary artery disease and another following a fourth allograft. The mortality rate for third-time heart allograft recipients is acceptable. These results are influenced by small sample size, younger age, case selection, and operations at select, high-volume institutions with significant experience.
Cardiac retransplantation is an efficacious therapy for primary cardiac allograft failure
Journal of Cardiothoracic Surgery, 2008
Background: Although orthotopic heart transplantation has been an effective treatment for endstage heart failure, the incidence of allograft failure has increased, necessitating treatment options. Cardiac retransplantation remains the only viable long-term solution for end-stage cardiac allograft failure. Given the limited number of available donor hearts, the long term results of this treatment option need to be evaluated.
Primary graft failure after cardiac transplantation: prevalence, prognosis and risk factors
Interactive cardiovascular and thoracic surgery, 2018
Primary graft failure (PGF) is a common and devastating complication, despite the advances in perioperative treatment. We aim to evaluate the prevalence of PGF and its impact on survival and to explore associated risk factors. From November 2003 through December 2015, 290 patients submitted to cardiac transplantation were classified into non-PGF (243; 84%) and PGF (47; 16%) groups. The characteristics of the recipients were similar regarding age (54.6 ± 10.6 vs 54.0 ± 9.4 years; P = 0.74), male gender (78.2% vs 72.3%; P = 0.38) and transpulmonary gradient (9.4 ± 4.2 vs 10.5 ± 5.6 mmHg; P = 0.15); donors to the PGF group had similar age (35.5 ± 11.4 vs 37.5 ± 10.7 years; P = 0.27) but were predominantly female (21% vs 42.6%; P = 0.002). Mean ischaemic (89.0 ± 36.8 vs 103.3 ± 44.7 min; P = 0.019) and cardiopulmonary bypass (92.8 ± 14.5 vs 126.3 ± 62.4 min; P < 0.001) times were longer in the PGF group. Length of hospital stay was 13.5 ± 7.5 vs 28.9 ± 35.2 days (P= 0.005). Hospital ...
Cardiac retransplantation: A viable option?☆
The Annals of Thoracic Surgery, 1992
To evaluate cardiac retransplantation as an appropriate utilization of scarce donor organs we analyzed data from the registry of the International Society for Heart and Lung Transplantation (ISHLT) (n = 449) and the Utah Cardiac Transplant Program (n = 20). Actuarial survival among retransplants was lower than in patients who received only one transplant in both the ISHLT registry patients (1 year survival, 48% versus 78%; p = 0.001) and the Utah series (1 year survival, 74% versus 88%; p =