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OBJECTIVE: Donation after circulatory death (DCD) heart transplantation potentially increases donor allografts, especially for patients with lower listing status. We assessed outcomes of DCD heart transplantation in patients bridged with durable left ventricular assist devices (LVAD). METHODS: The United Network for Organ Sharing (UNOS) database was queried for adult heart transplants utilizing DCD donors from 2019-2022. Patients were stratified between those with durable LVAD versus those with intra-aortic balloon pump, inotropic, or no bridging support (control group). Primary outcome was 1-year mortality. Secondary endpoints were hospital length of stay, stroke, pacemaker implantation, dialysis, and acute rejection before discharge. RESULTS: 160 LVAD recipients and 311 control recipients met study inclusion criteria. Recipients bridged with LVAD were younger (55 vs. 58 years, p<0.001) with lower BMI (28.3 vs. 30.3, p<0.001), longer waitlist times (112 vs. 34 days, p<0.001), longer out of body times (5.7 vs 4.6 hours, p<0.001), and less frequent normothermic regional perfusion (31% vs 40%, p=0.049). LVAD patients were commonly transplanted at UNOS status 3-4 (92%), while control patients were transplanted at status 2 (27%), status 3 (10%), status 4 (30%), or status 6 (30%). Kaplan-Meier analysis showed no difference in 1-year mortality between groups (p=0.34). However, acute rejection was higher in the unadjusted LVAD cohort (26% vs. 13%, p<0.001). On multivariable logistic regression, LVAD was an independent predictor of acute rejection (OR: 2.21, 95% CI:1.32-3.69, p=0.002). CONCLUSIONS: Durable LVAD may be associated with higher risk of developing an early inflammatory response in DCD heart transplantation; however, 1-year survival was similar between groups.
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BACKGROUND: Since United Network for Organ Sharing (UNOS) revised their heart allocation policy in 2018, usage of veno-arterial extracorporeal life support (VA-ECLS) has dramatically increased as a bridge to transplant. This study investigated outcomes of VA-ECLS patients bridged to simultaneous heart-kidney transplant (SHK) in the new policy era. METHODS: This study included 774 adult patients from the UNOS database who received SHK between 10/18/18 and 12/31/21 and compared patients bridged to transplant on VA-ECLS (n = 50) with those not bridged (n = 724). RESULTS: At baseline, SHK recipients bridged from VA-ECLS were younger (50.5 vs 58.0 years, p = 0.007), had higher estimated glomerular filtration rate (eGFR) at time of transplant (47.6 vs 30.1, p < 0.001), and spent fewer days on the waitlist (7.0 vs 33.5 days, p < 0.001). In the perioperative period, VA-ECLS was associated with higher rates of temporary dialysis (56.0% vs 28.0%, p < 0.001) but similar 2-year cumulative incidence of chronic dialysis (7.5% vs 5.4%, p = 0.800) and renal allograft failure (12.0% vs 8.1%, p = 0.500) compared to non-ECLS cohort. However, VA-ECLS patients had decreased survival to discharge (76.0% vs 92.7%, p < 0.001) and 2-year post-transplant survival (71.7% vs 83.0%, p = 0.004), as well as greater 2-year cumulative incidence of cardiac allograft failure (10.0% vs 2.7%, p = 0.002). Multivariable analyses found VA-ECLS at time of transplant to be independently associated with 2-year post-transplant mortality (HR [95% CI]: 3.40 [1.66-6.96], p = 0.001) and cardiac allograft failure (sub-distribution hazard ratio [SHR] [95% CI]: 8.51 [2.77-26.09], p < 0.001). CONCLUSION: Under the new allocation policy, patients bridged to SHK from VA-ECLS displayed greater early mortality and cardiac allograft failure but similar renal outcomes compared to non-ECLS counterparts.
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Objective: Congenital heart disease is a risk factor for mortality after orthotopic heart transplantation; however, the impact of preoperative circulation type and primary congenital heart disease diagnosis remains poorly delineated. Methods: We retrospectively reviewed patients with adult congenital heart disease aged 16 years or more who underwent orthotopic heart transplantation at our institution between 2008 and 2022. Patients were categorized as having single-ventricle or biventricular circulation. The primary end point was 5-year post-transplant survival. Results: Sixty-one patients with adult congenital heart disease (single-ventricle: n = 26 [42.6%], biventricular: n = 35 [57.4%]) underwent orthotopic heart transplantation at 33.7 [interquartile range, 19.1-48.7] years. The most common congenital heart disease diagnosis was hypoplastic left heart syndrome (n = 11, 42.3%) in the single-ventricle group and congenitally corrected transposition of the great arteries (n = 7, 20.0%) in the biventricular group. Twenty-four patients previously underwent Fontan palliation. At transplant, patients in the single-ventricle group were younger (18.5 [interquartile range, 17.6-32.3] years vs 45.0 [interquartile range, 33.0-52.2] years, P < .001) and more likely to have biopsy-proven cirrhosis (46.2% vs 14.3%, P = .01) and protein-losing enteropathy (42.3% vs 2.9%, P < .001). Patients in the single-ventricle group also had longer bypass times (223.4 ± 65.3 minutes vs 187.4 ± 59.5 minutes, P = .03) and longer durations of mechanical ventilatory support (3.5 [interquartile range, 2.0-6.0] days vs 1.0 [interquartile range, 1.0-2.0] days, P < .001). Operative mortality was comparable (11.5% vs 8.6%, P = 1). Median follow-up was 6.0 [interquartile range, 2.4-10.0] years. Five-year survival was worse in the single-ventricle group (66.0% ± 10.0% vs 91.3% ± 4.8%, P = .03), as was freedom from major rejection (58.3% ± 10.2% vs 84.0% ± 6.6%, P = .02). In univariable analysis, hypoplastic left heart syndrome and Fontan circulation were risk factors for post-transplant mortality (hypoplastic left heart syndrome: hazard ratio, 5.0, P < .001; Fontan: hazard ratio, 3.5, P = .03). Conclusions: Adult patients with congenital heart disease undergoing heart transplant with single-ventricle physiology experienced a more complicated post-transplant course, with worse long-term survival and freedom from rejection. Multicenter studies are required to guide orthotopic heart transplantation decision-making in this complex cohort.