Outcomes of heart transplantation in adult congenital heart disease with prior intracardiac repair
Kainuma A, Sanchez J, Ning Y, Kurlansky PA, Axsom K, Farr M, Sayer G, Uriel N, Takayama H, Naka Y, Takeda K.
Ann Thorac Surg. 2020 Sep 16:S0003-4975(20)31478-8. doi: 10.1016/j.athoracsur.2020.06.116. Online ahead of print.
Take Home Points:
- Operative risk in orthotopic heart transplantation is higher in ACHD patients with prior intracardiac repair as compared to propensity matched non-ACHD patients for both:
- 30-day mortality (8.2% vs. 3.9%, p=0.004)
- perioperative need of dialysis (22.7% vs. 13.3%, p<0.001)
- 10-year survival, however, is equivalent (ACHD 66.0% vs. control 64.1%, log-rank p=0.353)
- This data supports ACHD patients being listing for heart transplantation.
- Earlier listing of ACHD patients prior to the onset of end-organ dysfunction, and detailed preoperative planning with modern techniques including 3D modelling, may help reduce early surgical mortality.
Commentary by Dr. Timothy Roberts (Melbourne, Australia), section editor of ACHD Journal Watch: The proportion of cardiac transplants performed in ACHD patients remains low, despite a greater number requiring such intervention as survival improves and more patients face end stage heart failure. Data from earlier this century has demonstrated increased operative mortality, however more contemporary outcomes are lacking. This current paper is a retrospective analysis of ACHD patients with prior intracardiac repair undergoing orthotopic heart transplantation (OHT) between 2008 – 2019 using the United Network for Organ Sharing database.
Adult (age > 17) cardiac transplant recipients who had a history of prior sternotomy were divided into ACHD and non-ACHD (control) groups. 792 ACHD and 8385 non-ACHD patients were included for propensity score matching. Clinical (body mass index, diabetes, smoking, history of malignancy, history of cerebrovascular disease, creatinine, dialysis, total bilirubin, need for transfusion, extracorporeal membrane oxygenation, intra-aortic balloon pump, ventricular assist device, total times on waiting list, ventilator dependent, inotrope dependent, pulmonary capillary wedge pressure, ischemic time, functional status, intensive care unit stay) and demographic (age, gender) characteristics were used for propensity scoring. ACHD and control groups were matched 1:1; 486 (5.8%) cases in control and 486 (61.4%) in ACHD were matched successfully.
Table 1 shows ACHD and non-ACHD recipient group characteristics, before propensity score matching. At the time of transplant ACHD patients were younger, had a higher proportion of females, a higher total bilirubin at transplant, had spent more time on the waiting list, and were more inotrope dependent.
Table 2 illustrates 30-day post-transplant outcomes for ACHD and non-ACHD recipients after propensity score matching. ACHD patients had an increased need of dialysis, longer length of stay, and greater 30-day mortality. Risk factors for 30-day mortality in the ACHD group were BMI ( 25 kg/m2), history of cerebrovascular disease, dialysis after listing, total bilirubin ( 1.2 mg/dl), ischaemic time ( 4 hours), and donor age ( 50 years). The need for post-transplant dialysis had a profound impact on 10-year mortality in both ACHD (70.1% vs 45.1%, p<0.001) and non-ACHD (60.0% vs 28.4%, p<0.001) groups.
Findings from the current study again identify higher operative mortality. Likely explanations for this include the complex anatomical variation in ACHD patients, multiple prior palliative or corrective surgeries, and extensive reconstruction requirements with resultant longer ischemic time and increased bleeding risk.
The authors found pretransplant end-organ dysfunction and longer ischemic times were independent predictors of mortality. Earlier listing of ACHD patients prior to the onset of end-organ dysfunction, and detailed preoperative planning with modern techniques including 3D modelling may be beneficial.