Utility of the INTERMACS profile at the time of assessment for heart transplant.

The Interagency Registry of Mechanically Assisted Circulatory Support (INTERMACS) profiles are associated with mortality in heart failure patients undergoing ventricular assist device (VAD) implantation and heart transplantation (HTx). We assessed the prognostic value of the INTERMACS profile at the time of assessment for HTx or durable VAD implantation as bridge to candidacy (BTC). A total of 503 consecutive patients considered for HTx or VAD between 2006 and 2016 were included. The associations between INTERMACS profile and (a) waitlist mortality or delisting, (b) probability of HTx, and (c) overall mortality or delisting were evaluated using multivariable analysis. Median follow-up time was 2.9 years (IQR: 0.9-5.5) during which 184 received VAD, 347 received HTx, and 73 died (27 waitlist, 46 post-transplant). INTERMACS I-II profile was associated with higher waitlist mortality or delisting (HR: 3.83, 95% CI: 1.22-12.03), and this risk was reversed by VAD implantation (HR: 0.12, 95% CI: 0.03-0.50). INTERMACS III-IV profile was associated with a higher probability of HTx (HR: 1.82, 95% CI: 1.37-2.40). INTERMACS profile was not associated with the composite outcome of overall mortality or delisting. These results emphasize the prognostic utility of INTERMACS at time of decision for advanced therapies and its potential value in selecting patients for different interventions.

Validation of the International Society for Heart and Lung Transplantation primary graft dysfunction instrument in heart transplantation.

BACKGROUND: In 2014, the International Society for Heart and Lung Transplantation (ISHLT) developed a classification instrument for left ventricular (LV) and isolated right ventricular (RV) primary graft dysfunction post‒heart transplant. The instrument classifies LV-PGD as mild, moderate, or severe. In this study, we evaluated the predictive validity of this instrument. METHODS: We conducted a cohort study of 412 consecutive patients transplanted between 2004 and 2015 at the Toronto General Hospital and Ottawa Heart Institute (Canada). We classified LV-PGD as mild, moderate, or severe, using the ISHLT instrument. To assess predictive validity, we evaluated the association between LV-PGD severity and 1-year post-transplant mortality using a Cox regression model adjusted for recipient age. RESULTS: The cohort was predominantly male (71%), mean age 50 ± 13 years, mean donor age 38 ± 14 years, with 25% female donors. Mean ischemic time was 3.7 ± 1.1 hours. LV-PGD was mild in 3.6% of patients, moderate in 9.5%, and severe in 3.9%. All levels of LV-PGD were associated with increased 1-year mortality, with a gradient in the association between mild, moderate, and severe. We only observed a statistically significant association for moderate and severe forms of LV-PGD (mild: hazard ratio [HR] 2.4, 95% confidence interval [CI] 0.6 to 10.2; moderate: HR 7.0, 95% CI 3.4 to 14.6; severe: HR 15.9, 95% CI 7.2 to 35.0). CONCLUSIONS: The ISHLT LV-PGD classification convincingly identifies a substantial increase in the risk of death at 1 year, and an increased gradient of risk, in those with moderate or severe LV-PGD.