Long-Term Transplant Outcomes of Donor Hearts with Left Ventricular Dysfunction
Agustin Sibona1, Kiran K. Khush2, Udo E. Oyoyo1, Timothy P Martens1, Nahidh W. Hasaniya1, *Anees J. Razzouk1, *Leonard L. Bailey1, *David G. Rabkin1
1Loma Linda University Medical Center, Loma Linda, CA;2Stanford University Medical Center, Palo Alto, CA
Despite several single-center reports demonstrating acceptable short and medium term transplant outcomes using donor hearts (DH) with left ventricular (LV) systolic dysfunction, 19% of hearts eligible for transplantation in the current era are not utilized exclusively due to LV dysfunction. The purpose of this study was to investigate modern, long-term outcomes of transplanted DH with LV systolic dysfunction with a large cohort from a diverse group of transplant centers.
METHODS: Using the United Network for Organ Sharing transplant database, we reviewed all adult, isolated heart transplants between January 1, 2000 and March 31, 2016. Transplanted DH were divided into four groups: Group 1: LV ejection fraction (EF) ≥ 55%, Group 2: LVEF 40-49%, Group 3: LVEF 30-39% and Group 4: LVEF 20-29%. DH with no recorded LVEF, LVEF < 20% and LVEF ≥ 50% but < 55% were excluded from the study. Kaplan-Meier survival curves were compared among recipient groups. A covariates-adjusted Cox regression model with robust standard errors was developed to estimate post-transplant mortality Hazard Ratios (HR) with 95% confidence intervals (CI) for LV dysfunction. Covariates in the model included donor and recipient age, gender, race, body mass index and mechanism of death. Baseline characteristics and postoperative length of stay (LOS) were also compared between groups.
RESULTS: 31,735 DH were transplanted during the study period (Group 1: n=28,044, Group 2: 595, Group 3: 96, Group 4: 21) 279 were excluded for not having a recorded LVEF, 758 were excluded for LVEF < 20% and 1,942 were excluded for LVEF ≥ 50% but <55%. Median follow-up was 4,333 days. Comparison of Kaplan-Meier curves revealed no statistically significant differences in recipient survival between groups up to 6000 days of follow up (P=0.105, Log-Rank test) although there was a statistically insignificant trend towards reduced survival in Group 4 that became apparent after 3000 days. Covariates-adjusted HR for LV dysfunction showed that for every 10% point increase in LVEF, there was a 1.2% decrease in mortality (HR=0.988, 95% CI=0.991-1.001). DH with diminished LVEF were younger (Group 1: 32.1±12.0, Group 2: 27.6±10.9, Group 3: 23.9±8.8, Group 4: 22.9±9.0, p<0.001), more likely to be from male donors (Group 1 %male: 70.45%, Group 2: 74.29%, Group 3: 78.13% and Group 4: 71.43, p<0.001)and had lower mean body mass index (Group 1: 26.9±5.6, Group 2: 25.5±4.7, Group 3: 24.6±4.9, Group 4: 25.2±5.2, p < 0.001). Differences in postoperative LOS were significant (Group 1: 20.32 days ±23.79 SD, Group 2: 23.89±28.48, Group 3: 31.19±52.93 and Group 4: 12.6±8.03, p=0.0007).
CONCLUSIONS: Selected DH with LVEF 40-49% can be transplanted with recipient survival equivalent to DH with normal LV systolic function. Although hospital LOS is increased in recipients of DH with LVEF 30-39%, these hearts may be transplanted with excellent long-term outcomes. Carefully selected potential DHs with LVEF ≥ 30% should not be excluded from consideration of transplantation on the basis of depressed LVEF alone.
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