Heart failure survival score continues to predict clinical outcomes in patients with heart failure receiving β-blockers

BACKGROUND: The Heart Failure Survival Score (HFSS) has been previously shown to effectively risk-stratify patients under evaluation for heart transplantation. However, this model was developed before broad use of beta blockade. We hypothesized that the prognostic tool would retain its ability to risk stratify patients treated with beta-blockers. METHODS: We collected clinical data on 524 consecutive patients referred for heart transplantation from 1994 to 2001. Kaplan-Meier survival analysis and multivariable Cox regression analysis were performed with events defined as death, left ventricular assist device placement, or United Network of Organ Sharing 1 heart transplantation. RESULTS: Kaplan-Meier analysis of the patient population revealed effective discrimination by the survival score both for beta-blocker treated and untreated patients (both p <0.0001). Two-year event-free survival was 94% +/- 2% and 84% +/- 4% for beta-blocker and no beta-blocker patients in the low-risk HFSS strata. Cox proportional hazard modeling showed that HFSS strata (medium risk: HR 2.65, 95% CI 1.75-4.02, p <0.001; high risk: HR 5.51, 95% CI 3.64-8.33, p <0.001) and beta-blocker treatment (HR 0.45, 95% CI 0.31-0.64, p <0.001) were significant predictors of event-free survival. Receiver operating curves (area under the curve) for HFSS strata used to predict 2-year events were similar for beta-blocker treated (0.78 +/- 0.04) and untreated (0.80 +/- 0.03) patients. CONCLUSIONS: The HFSS provides effective risk stratification with or without beta-blocker therapy. Consideration of beta-blocker therapy with survival score strata improves outcome prediction in patients evaluated for heart transplantation.     

Aminoterminal pro type B natriuretic peptide as a predictive and prognostic marker in patients with chronic heart failure.

BACKGROUND: B-type natriuretic peptide (BNP) is released from the cardiac ventricles in response to increased wall tension. We studied the relation of NT-proBNP to Heart Failure Survival Score (HFSS) and New York Heart Association (NYHA) class in patients with chronic heart failure (CHF). We also studied the impact for recipient selection for cardiac transplant and assessed it as a predictive and prognostic marker of CHF. METHODS: A total of 550 patients with dilative cardiomyopathy (n = 323), and coronary artery disease (n = 227) were prospectively examined. All patients underwent spiroergometry, echocardiography, right heart catheterization, and electrocardiogram. Routine blood levels and NT-proBNP were measured. The clinical selection for cardiac transplant candidates was adjudicated by 2 independent cardiologists who were blinded to the results of NT-proBNP assays. Clinical outcome and predictive power of NT-proBNP were analyzed. RESULTS: NT-proBNP levels in patients clinically considered for cardiac transplantation were significantly higher (2293 ng/ml vs 493 ng/ml; p < 0.001). The receiver operating characteristic (ROC) analysis regarding transplant candidacy showed an area under the ROC curve (AUC) of 0.84 +/- 0.01 for HFSS, 0.86 +/- 0.001 for NYHA, and 0.96 +/- 0.01 for NT-proBNP. Patients with increasing NT-proBNP levels or remaining elevated levels despite adequate heart insufficiency treatment were maintained with left ventricular assist device implantation (n = 10) or urgent heart transplantation (n = 2). Patients with NT-proBNP levels above 5000 pg/ml had a mortality rate of 28.4% per year. Twenty-eight patients died during the observation period; all these patients were within NYHA Classes 3 and 4 (NT-proBNP 5423 +/- 423 ng/ml). CONCLUSIONS: NT-proBNP discriminates patients at high likelihood of being a candidate for transplantation and provides prognostic informations in patients with CHF. NT-proBNP levels above 5000 pg/ml at admission were associated with death, and these levels markedly discriminated candidates for left ventricular assist devices or urgent transplantation.     

Survival benefits of heart and lung transplantation.

OBJECTIVE: Heart and lung transplantation has gained acceptance as therapy for end-stage cardiac and pulmonary failure. The early and intermediate survival benefits of one center's 10-year experience with 177 patients undergoing thoracic transplantation were examined. SUMMARY BACKGROUND DATA: As experience in cardiac and pulmonary transplantation has increased, improvements in patient selection, organ preservation, preoperative support, and perioperative care have significantly reduced the early threats to patient survival. Graft dysfunction due to chronic rejection appears to be the main risk for longer-term survival, and data compiled by the United Network for Organ Sharing (UNOS) indicate a 70% 5-year survival for heart transplants and a 50% 5-year survival for lung transplant recipients. METHODS: The medical records of 120 heart recipients, 52 lung transplant recipients, and 5 heart-lung recipients were reviewed. Cumulative survival estimates were made using Kaplan-Meier analysis. The etiologies of operative and long-term mortality in each transplant population were identified. A comparison of long-term survival after heart transplantation versus coronary revascularization in a group of patients with ischemic cardiomyopathy was performed. RESULTS: Operative mortality in both the cardiac and pulmonary transplant recipients was 8%. From 1990 to 1995, 70 consecutive adult cardiac transplant procedures were performed without an operative mortality. Three of five patients survived heart-lung transplantation. The extended actuarial survival rate at 5 years was 80% for the cardiac transplant recipients. The 2-year actuarial survival rate for the lung transplant recipients was 88%. Graft dysfunction was the most common cause of operative mortality in the heart transplant group whereas infection was responsible for most of the operative mortality after lung transplantation. CONCLUSIONS: Cardiac and pulmonary transplantation can be applied to morbidly ill patients with excellent operative and intermediate-term survival.     

Predicting coronary heart disease in renal transplant recipients: a prospective study

BACKGROUND: Current cardiovascular risk calculators, widely used in the general population, have not yet been validated in renal transplant recipients. We conducted a prospective study to determine the incidence and risk factors for ischemic heart disease in renal transplant recipients and to assess the relevance of the Framingham Heart Study risk calculator in this population. METHODS: Three hundred and forty four consecutive renal transplant recipients free of vascular disease were enrolled. Coronary events were registered and analyzed with respect to traditional and nontraditional cardiovascular risk factors. The risk of coronary events was assessed through the Framingham Heart Study formula and the relevance of this equation was then analyzed. RESULTS: The patients were followed for a mean duration of 72 +/- 14 months. Twenty seven coronary events occurred in 27 patients (7.8%). In addition to risk factors included in the Framingham Heart Study score, C-reactive protein (CRP) level (P= 0.009), and hyperhomocysteinemia (P= 0.01) were found to be independent risk factors for ischemic heart disease events in renal transplant recipients. The Framingham Heart Study model did not predict absolute ischemic heart disease risk in the transplant population as a whole. CONCLUSION: Nontraditional cardiovascular risk factors greatly contribute to increased incidence of ischemic heart disease events in renal transplant recipients. They should therefore be considered in preventive care of these patients which relies on reduction of overall absolute risk. Although the Framingham Heart Study score has an excellent predictive value in low-risk renal transplant recipients, it tends to underestimate the real cardiovascular risk in high-risk patients.     

Differences in clinical profile and survival after heart transplantation according to prior heart disease

OBJECTIVE: The objective of this study was to compare baseline characteristics and long-term survival among patients undergoing heart transplantation (HT) according to the 3 main types of prior heart disease: ischemic, idiopathic dilated cardiomyopathy (IDC), and valvular. MATERIALS AND METHODS: Four hundred twenty-three HTs performed between 1989 and 2005 were included. We excluded pediatric transplantation, retransplantations, combined transplantations (lung and kidney), and transplantations due to heart diseases other than ischemic, IDC, and valvular. Baseline characteristics of the recipients were analyzed, as well as short-term and long- term survival by groups. Analysis of variance (ANOVA) was used for continuous variables and chi-square was used for categorical variables. Survival analysis was computed using Kaplan-Meier curves and the log-rank test, as well as multivariate analysis using logistic regression. RESULTS: The ischemic and valvular heart disease groups were older and had a more frequent history of prior heart surgery and circulatory support at the time of transplantation compared with the IDC group. The incidence of arterial hypertension and dyslipidemia was higher among ischemic heart disease recipients. Survival rates at 30 days did not show significant differences (ischemic, 88%; IDC, 93%; and valvular; 84%; P = .21). Long-term survival rates were greater in the IDC than in the valvular or ischemic heart disease groups (75% vs 65% and 62%, respectively; P = .021). The multivariate analysis showed an association between the IDC group and long-term survival (odds ratio [OR], 0.55; 95% confidence interval [CI] 0.35-0.89; P = .015). CONCLUSIONS: (1) Patients showed a different clinical profiles depending on their pretransplantation heart disease. (2) There were no differences in early mortality between the groups. (3) Long-term survival was significantly greater among IDC transplant recipients and similar in ischemic and valvular heart disease transplant recipients.     

Performance of existing risk scores around heart transplantation: validation study in a 4‐year cohort

Several risk scores exist to help identify best candidate recipients for heart transplantation (HTx). This study describes the performance of five heart failure risk scores and two post‐HTx mortality risk scores in a French single‐centre cohort. All patients listed for HTx through a 4‐year period were included. Waiting‐list risk scores [Heart Failure Survival Score (HFSS), Seattle Heart Failure Model (SHFM), Meta‐Analysis Global Group in Chronic Heart Failure (MAGGIC), Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE‐HF) and Get With The Guidelines‐Heart Failure (GWTG‐HF)] and post‐HTx scores Index for Mortality Prediction After Cardiac Transplantation (IMPACT and CARRS) were computed. Main outcomes were 1‐year mortality on waiting list and after HTx. Performance was assessed using receiver operator characteristic (ROC), calibration and goodness‐of‐fit analyses. The cohort included 414 patients. Waiting‐list mortality was 14.0%, and post‐HTx mortality was 16.3% at 1‐year follow‐up. Heart failure risk scores had adequate discrimination regarding waiting‐list mortality (ROC AUC for HFSS = 0.68, SHFM = 0.74, OPTIMIZE‐HF = 0.72, MAGGIC = 0.70 and GWTG = 0.77; all P‐values <0.05). On the contrary, post‐HTx risk scores did not discriminate post‐HTx mortality (AUC for IMPACT = 0.58, and CARRS = 0.48, both P‐values >0.50). Subgroup analysis on patients undergoing HTx after ventricular assistance device (VAD) implantation (i.e. bridge‐to‐transplantation) (n = 36) showed an IMPACT AUC = 0.72 (P < 0.001). In this single‐centre cohort, existing heart failure risk scores were adequate to predict waiting‐list mortality. Post‐HTx mortality risk scores were not, except in the VAD subgroup.     

Composite risk scores and depression as predictors of competing waiting‐list outcomes: the Waiting for a New Heart Study

We evaluated two composite risk scores, (Heart Failure Survival Score, HFSS; German Transplant Society Score, GTSS), and depression as predictors of mortality and competing waiting‐list outcomes [high‐urgency transplantation (HU‐HTx), elective transplantation, delisting because of clinical improvement] in 318 heart transplant (HTx) candidates (18% women; aged 53 ± 11 years) from 17 hospitals and newly registered with Eurotransplant. Demographic variables and depression (Hospital Anxiety and Depression Scale, HADS) were assessed using questionnaires. Variables to compute HFSS and GTSS, age, medications, and outcomes were provided by Eurotransplant. At 12 months, 33 patients died, 83 received urgent HTx, 30 elective HTx, and 17 were delisted because of improvement. Applying cause‐specific Cox regressions, only the HFSS was significantly associated with 1‐year mortality [HR = 0.64 (95% CI = 0.43–0.95), P = 0.029]. The GTSS was the strongest predictor of HU‐HTx [HR = 1.02 (95% CI = 1.01–1.02), P < 0.001]. Low depression scores contributed significantly to clinical improvement, even after adjusting for age and risk scores [HADS: HR = 0.12 (95% CI = 0.02–0.89), P = 0.039]. These findings confirm the usefulness of composite risk scores for the prediction of mortality and HU‐HTx, validating both scores for their intended use. The finding that depression was an independent predictor of the waiting‐list outcome clinical improvement suggests that considering patients’ psychological attributes in addition to their medical characteristics is advisable.     

The paradox of survival results after heart transplantation for cardiomyopathy caused by Trypanosoma cruzi

Background. Donor supply limits heart transplantation (HT) and relative priority should be given to cases with greater chances of success. The objectives of this multicenter study were (1) to determine the survival rate after heart transplantation for patients with Chagas’ heart disease (ChHD) in comparison with other causes; and (2) to identify the causes of death specifically due to reactivation of the Trypanosoma cruzi infection.Methods. We studied 720 patients who had undergone orthotopic heart transplantation and were followed in 16 heart transplantation centers. The etiology was idiopathic dilated cardiomyopathy in 407 patients, ischemic cardiomyopathy in 196 patients, and ChHD in 117 patients.Results. Follow-up was 2.87 ± 3.05 years (from 1 month to 13.85 years). Survival of ischemic recipients at 1, 4, 8, and 12 years was 59%, 44%, 34%, and 22%, respectively; for idiopathic dilated cardiomyopathy it was 69%, 57%, 40%, and 32%; and for ChHD it was 71%, 57%, 55%, and 46% (p < 0.027). In ischemic recipients the most frequent causes of death were infection (15.3%), acute graft failure (13.3%), and graft coronary artery disease/sudden death (7.7%). In idiopathic dilated cardiomyopathy the causes were infection (11.1%), rejection (9.6%), and acute graft failure (9.1%). In ChHD the causes were infection (10.3%), rejection (10.3%), and neoplasm (4.3%). In ChHD, reactivation of the cruzi infection was the cause of death in 2 patients.Conclusions. The survival results after heart transplantation are paradoxical according to the usually high expected death rates for Chagas’ disease. Heart transplantation for ChHD should be regarded as a valuable treatment option.     

The paradox of survival results after heart transplantation for cardiomyopathy caused by Trypanosoma cruzi. First Guidelines Group for Heart Transplantation of the Brazilian Society of Cardiology.

Background. Donor supply limits heart transplantation (HT) and relative priority should be given to cases with greater chances of success. The objectives of this multicenter study were (1) to determine the survival rate after heart transplantation for patients with Chagas’ heart disease (ChHD) in comparison with other causes; and (2) to identify the causes of death specifically due to reactivation of the Trypanosoma cruzi infection.

Methods. We studied 720 patients who had undergone orthotopic heart transplantation and were followed in 16 heart transplantation centers. The etiology was idiopathic dilated cardiomyopathy in 407 patients, ischemic cardiomyopathy in 196 patients, and ChHD in 117 patients.

Results. Follow-up was 2.87 ± 3.05 years (from 1 month to 13.85 years). Survival of ischemic recipients at 1, 4, 8, and 12 years was 59%, 44%, 34%, and 22%, respectively; for idiopathic dilated cardiomyopathy it was 69%, 57%, 40%, and 32%; and for ChHD it was 71%, 57%, 55%, and 46% (p < 0.027). In ischemic recipients the most frequent causes of death were infection (15.3%), acute graft failure (13.3%), and graft coronary artery disease/sudden death (7.7%). In idiopathic dilated cardiomyopathy the causes were infection (11.1%), rejection (9.6%), and acute graft failure (9.1%). In ChHD the causes were infection (10.3%), rejection (10.3%), and neoplasm (4.3%). In ChHD, reactivation of the cruzi infection was the cause of death in 2 patients.

Conclusions. The survival results after heart transplantation are paradoxical according to the usually high expected death rates for Chagas’ disease. Heart transplantation for ChHD should be regarded as a valuable treatment option.     

Cardiac transplantation using extended-donor criteria organs for systemic amyloidosis complicated by heart failure

BACKGROUND: Systemic amyloidosis complicated by heart failure is associated with high cardiovascular morbidity and mortality. Heart transplantation for patients with systemic amyloidosis is controversial due to recurrence of disease in the transplanted organ or progression of disease in other organs. METHODS: All patients with systemic amyloidosis and heart failure referred for heart transplant evaluation from 1997 to 2004 were included in this retrospective cohort analysis. An interdisciplinary protocol for cardiac transplantation using extended-donor criteria organs, followed in 6 months by either high-dose chemotherapy and stem cell transplantation for patients with primary (AL) or by orthotopic liver transplantation for familial (ATTR) amyloidosis, was developed. Survival of the transplanted amyloid cohort was compared to survival of those amyloid patients not transplanted and to patients transplanted for other indications. RESULTS: A total of 25 patients with systemic amyloidosis and heart failure were included in the study; 12 patients received heart transplants. Amyloid heart transplant recipients were more likely female (58% vs. 8%, P=0.02) and had lower serum creatinine (1.3+/-0.5 vs. 2.0+/-0.7 mg/dL, P=0.01) than nontransplanted amyloid patients. Survival at 1-year after heart transplant evaluation was higher among transplanted patients (75% vs. 23%) compared to patients not transplanted (P=0.001). Short-term survival posttransplant did not differ between transplanted amyloid patients and contemporaneous standard and extended-donor criteria heart transplant patients (P=0.65). CONCLUSIONS: Cardiac transplantation for amyloid patients with extended-donor criteria organs followed by either stem cell or liver transplantation is associated with improved survival compared to patients not transplanted. Short- to intermediate-term survival is similar to patients receiving heart transplantation for other indications. This clinical management strategy provides cardiac amyloid patients a novel therapeutic option.     

Heart transplantation in insulin–treated diabetic patients with diabetes–related complications

Heart transplantation is the most effective therapy for end-stage heart failure in patients with diabetes mellitus (DM). However, diabetes-related complications (DRCs) are a relative contraindication for heart transplantation. Nevertheless, the increasing prevalence of both DM and congestive heart failure makes it necessary to perform heart transplantation even in those patients with advanced DM. We performed a retrospective analysis on long-term survival in 47 patients with insulin-treated DM and DRCs (group 1). Survival rate and causes of death were compared with data of a group of heart transplant recipients without DM (n = 1061, group 2). Mean follow-up time of all heart transplant recipients was 68.2 months (range: 0-204 months). Overall mortality during follow-up was 42.9%. Long-term survival did not differ significantly between study groups, but tended to be shorter in group 1 than in group 2 (P = 0.07). In group 1, steroid-free immunosuppressive therapy was associated with a higher percentage of long-term survivors compared with no steroid-free immunosuppression. Our data demonstrate that long-term survival is acceptable in heart transplant recipients with preoperatively diagnosed DM and DRCs. Consequently, advanced DM should no longer be a relative contraindication for heart transplantation.     

The Influence of the Recipient's Body Weight on the Probability to Obtain a Heart Transplant—POLKARD HF Registry

Introduction

The aim of the study was to analyze the influence of body weight of the adult heart recipient on the chance to obtain a transplant.

Methods

We analyzed the data from all 658 patients listed for heart transplantation.

Results

During the follow-up period, 325 (49%) of listed patients underwent transplantation with 102 (15%) succumbing before heart transplantation. The mean weight of transplanted patients was 73.7 ± 13.7 kg and 81.2 ± 15.4 kg for those not transplanted (P < .00001). Patients were divided according to body weight in two groups: light = below 80 kg (n = 360) or heavy ≥ 80 kg or above (n = 297). On the transplant list, 111 heavy patients (37%) versus 213 light patients (59%) underwent the procedure, a significant difference.The waiting time among light patients was 255 versus heavy patients of 395 days (P < .005).There was a similar number of deaths before transplantation among the light (n = 56 360 patients; 15.5%) versus the heavy group (49/297; 16%).Upon multivariate Cox mode analysis independent factors related to not receiving a heart transplant were greater weight, systolic blood pressure, pulmonary vascular resistance, Heart Failure Survival Score (HFSS) score and lower N-terminal pro-brain natriuretic peptide (NTproBNP) levels.

Conclusions

Among adult heart transplant candidates, the chance to receive a heart transplant significantly decreased when the recipient's weight exceeded 80 kg. Patients with a body weight more than 110 kg had a poor chance to receive a heart transplantation.     

Partial left ventriculectomy for dilated cardiomyopathy: is this an alternative to transplantation?

OBJECTIVE: To determine the late effectiveness of partial left ventriculectomy and risk factors for failure. METHODS: Between May 1996 and December 1998, partial left ventriculectomy and concomitant mitral valve surgery were performed in 62 patients (95% transplant candidates) with a mean age of 54 years (range 17-72 years). All patients were in New York Heart Association functional class III (38%) or IV (62%) because of idiopathic dilated cardiomyopathy (59 patients) or ischemic, valvular, or familial cardiomyopathy (1 patient each). Outcomes considered for multivariable analysis included implantation of left ventricular assist device, return to class IV heart failure, relisting for transplantation, and death. RESULTS: Partial left ventriculectomy reduced the left ventricular end-diastolic diameter immediately preoperatively to immediately postoperatively (from 8.4 +/- 1.1 cm to 5.92 +/- 0.8 cm; P =.01), reduced the left ventricular end-diastolic volume index (from 133 +/- 48.6 mL to 64.1 +/- 26 mL; P <.0001), and increased the left ventricular ejection fraction (from 16 +/- 7.6 to 31.5 +/- 10.9; P <.0001). Survival was 80% and 60% at 1 and 3 years after surgery and freedom from failure was 49% and 26%, respectively. Increased systolic pulmonary artery pressure, decreased maximum exercise oxygen consumption, and increased left atrial pressure were associated with failure and/or death. The degree of preoperative mitral regurgitation did not correlate with clinical outcome. CONCLUSIONS: Early and late failures preclude the widespread use of partial left ventriculectomy. However, in view of its sometimes beneficial effect, use in situations that do not allow for transplantation or as a biologic bridge to transplantation may be appropriate.     

Survival of patients removed from the heart transplant waiting list

OBJECTIVE: End-stage heart failure has been associated with high mortality in the absence of transplantation. We evaluated the outcome of patients receiving optimal medical therapy who were removed from the cardiac transplant waiting list to determine survival and predictors of mortality. METHODS: We performed a retrospective review of 27 patients removed from the cardiac transplant waiting list from 1999 to 2001 at our institution. RESULTS: Mean age was 53 +/- 11 years; 16 of the patients were male. Status was IB in 3 cases and II in 24. Median time on the list was 32 months, and median follow-up was 2.9 years. Patients were removed from the transplant list because of either clinical improvement (group A, n = 18) or deterioration (group B, n = 9). In group A, 13 patients had improved functional status and 10 were in New York Heart Association class 1 or 2; 16 had improved echocardiographic left ventricular function. Survivals at 3 years were 100% in group A and 44% in group B (P <.01). CONCLUSION: Patients with end-stage heart failure who have clinical response to medical therapy have excellent 3-year survival. These data suggest the necessity of close evaluation of patients waiting for transplantation, with a low threshold for inactivation if persistent clinical improvement is observed.     

Special report from the heart transplant candidate registry committee in Japan.

BACKGROUND: Heart transplantation had been withheld for long time in Japan. In October 1997 organ transplant legislation was implemented and the heart transplantation program began. In February 1999 the first heart transplantation was performed. Since then a total of 17 successful transplantations have been done. METHODS: This report describes the profiles of heart transplant applicants presented to the Heart Transplant Candidate Registry Committee of the Japanese Circulation Society from 1997 to 2003. RESULTS: Two hundred eighty-four applications were submitted to the Committee for the evaluation. All applicants were <60 years of age (mean 32 years). Ninety-two percent of these applicants had chronic severe heart failure with New York Heart Association (NYHA) Class III or IV status. Etiology of heart failure was dilated cardiomyopathy in 80% of applicants, although only 6% had ischemic heart disease, which is in notable contrast to Western countries. Most applicants died while waiting for transplantation and thus only 17 patients underwent heart transplantation, with an average waiting time of 514 days. Recipient prognosis was satisfactory with a survival rate of 100%. CONCLUSION: In Japan, heart transplantation is not yet considered a viable treatment option for severe heart failure.     

Risk factors affecting survival in heart transplant patients

BACKGROUND: Certain cardiovascular risk factors have been linked to morbidity and mortality in heart transplant (HT) patients. The sum of various risk factors may have a large cumulative negative effect, leading to a substantially worse prognosis and the need to consider whether HT is contraindicated. The objective of this study was to determine whether the risk factors usually available prior to HT result in an excess mortality in our setting that contraindicates transplantation. MATERIALS AND METHODS: Consecutive patients who underwent heart transplantation from November 1987 to January 2004 were included. Heart-lung transplants, retransplants, and pediatric transplants were excluded. Of the 384 patients, 89% were men. Mean age was 52 years (range, 12 to 67). Underlying disease included ischemic heart disease (52%), idiopathic dilated cardiomyopathy (36%), valvular disease (8%), and other (4%). Variables considered risk factors were obesity (BMI >25), dyslipidemia, hypertension, prior thoracic surgery, diabetes, and history of ischemic heart disease. Survival curves by number of risk factors using Kaplan-Meier and log-rank for comparison of curves. RESULTS: Overall patient survival at 1, 5, 10, and 13 years was 76%, 68%, 54%, and 47%, respectively. Survival at 10 years, if fewer than two risk factors were present, was 69%; 59% if two or three factors were present; and 37% if more than three associated risk factors were present (P = .04). CONCLUSIONS: The presence of certain risk factors in patients undergoing HT resulted in lower survival rates. The combination of various risk factors clearly worsened outcomes. However, we do not believe this should be an absolute contraindication for transplantation.     

Sudden death and tailored medical therapy in elective candidates for heart transplantation.

BACKGROUND: Due to the shortage of donor organs there is a long waiting time for heart transplantation. As a consequence, a high mortality rate on the waiting list diminishes the potential benefit of the procedure. Tailored medical therapy optimized according to the individual patients demands was introduced to select responding HTx candidates for continued management without transplantation. The development of modes of death over time (heart failure, sudden arrhythmic) in this population is unknown. METHODS: In 434 elective candidates for heart transplantation, submitted to our institution in the years 1984-1997 (50% coronary artery disease, mean age 51.6 +/- 12 years, 86% males) medical therapy was adjusted according to the results of repeated right heart catherizations. Adjuncts to conventional therapy with ACE inhibitors, digitalis and diuretics were amiodarone, beta-blockers, spironolactone, oral anticogulants, molsidomine or nitrates. Only patients not responding to these measures were processed to HTx. Clinical events (death, mode of death, HTx, resuscitation) were noted and analyzed by the Kaplan-Meier method and related to patients characteristics by multivariance analysis. RESULTS: During the mean follow-up of 2.36 +/- 2.4 years only 113 patients (25%) received a donor heart. One hundred-sixteen patients (26%) died without transplantation. Eighty-three (72%) of the deaths were sudden, 24 (20%) due to progression of heart failure and 9 (8%) due to other reasons. A shift from heart failure to sudden death was observed. Including 8 successful resuscitations due to documented VT/VF, there is a 20% risk of having a major arrhythmic event during the first two years of observation. Long-term (>1 year) medical responders had better hemodynamics at entry. Patients who died suddenly had similar clinical and hemodynamic data at entry than patients who needed an early transplant, but were in a comparable NYHA stage before death than long-term medical responders (2.15 +/- 0.8 vs 1.82 +/- 0.6, NS). Patients dying suddenly had significant more ventricular premature beats (1.6 +/- 2.9%/24 hours vs 1.06 +/- 2.8%/24 hours, p < .01) and complex ventricular arrhythmias (7.3 +/- 2.7/24 hours vs 1.98 +/- 5.6/24 hours, p < .01) than long-term responders. Seventy-five percent of all sudden death occurred during the first 2 observation years. CONCLUSIONS: The rate of heart failure death in elective candidates for heart transplantation under optimized medical therapy is low when patients are followed closely and transplant can be done rapidly after deterioration is recognized. Sudden death represents the highest risk for most patients. This event occurred predominantly in stable patients under tailored medical therapy without indication for HTx at that time. Our results strongly demand strategies for risk stratification and the investigation of prophylactic measures in this population.     

Surgery in heart and lung transplant patients

BACKGROUND: Heart and lung transplantation is an increasingly successful procedure. After transplant, these patients may need surgery for common diseases and for problems caused by immunosuppression. The purpose of this study was to determine surgical outcomes heart and lung transplant patients after transplantation. METHODS: All patients in the cardiopulmonary transplant registry were reviewed. Data collected included sex, age at transplantation, age at subsequent procedure, number and type of surgical procedures performed, number and type of postoperative complications, grade of complications (using the Clavien classification), and outcome (discharge to home, disabled, dead). RESULTS: During a 15-year period, 222 (64%) of 345 heart or lung transplant patients underwent a surgical procedure. Seven hundred fifty-four procedures were performed (median 3 procedures/patient). Sixty-seven patients suffered 72 complications (10% complication rate). Twenty-one (29%) complications were grade I; 20 (28%) were grade IIA; 21 (29%) were grade IIB; 8 (11%) were grade III; and 2 (3%) were grade IV. Twelve percent of the complications in the heart transplant patients were cardiac in nature, whereas 0% of the complications in the lung transplant patients were pulmonary in nature. There were 475 (63%) discharges to home, 2 (0.2%) inpatient deaths, and 18 (2%) deaths within 30 days; 49 (7%) procedures resulted in disability; and 210 (28%) patients were lost to follow-up. CONCLUSIONS: Heart or lung transplant patients will frequently need subsequent surgical procedures. Overall, the patients tolerated the procedures well, and the morbidity and mortality rates were acceptable. Most complications were not related to the transplanted organ.     

Risk factor analysis for the major hazards following heart transplantation--rejection, infection, and coronary occlusive disease

This study demonstrates the importance of analyzing survival by cause of death in order to achieve a better understanding of the prognostic indicators involved. It further emphasizes the need for analysis of risk factors in both univariate and multivariate models, and the danger of making judgements based on premature analysis of data on follow-up after heart transplantation. Survival following transplantation is characterized by the major hazards of early death due to infection and rejection and late graft loss due to coronary occlusive disease (COD). This study summarizes the first-graft survival experience for 323 transplant patients at Papworth Hospital, and assesses a number of potential risk factors for (1) early mortality, (2) late mortality from COD, and (3) development of COD. The potential risk factors considered for all hazards are donor and recipient age, sex, blood group, and matching of these factors; donor cause of death and recipient immunosuppression; inotropic support; waiting time; preoperative diagnosis and previous cardiac surgery; ischemic time; and extubation time. In addition, for development of, and graft loss from, COD, perioperative rejection and cytomegalovirus infection; hypertension at discharge; and cholesterol, triglycerides, and lipids at two years were assessed as risk factors. Advances in immunosuppression were observed to have increased overall survival rates and decreased mortality from infection, rejection, and COD, as well as decreasing morbidity from COD. Fatal rejection was found to be more likely in female recipients, recipients over 40 years, recipients of grafts from donors over 30 years old, patients who were transplanted for valvular heart disease, and patients who waited less than three months for their transplant. Male recipients of female donor organs were more likely to lose their grafts as a result of COD. Patients older than 50 and hearts from donors older than 40 conferred a high risk of development of and loss from COD. Patients transplanted for ischemic heart disease were more likely to develop COD. High cholesterol, low HDL, high LDL, and high triglycerides at two years after transplant showed some evidence of high risk for the subsequent development of COD, although these relationships are not statistically significant at this stage. Contrary to other recent studies, cytomegalovirus infection was not found to be a risk factor for the development of COD.