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Outcomes in patients undergoing cardiac retransplantation: A propensity matched cohort analysis of the UNOS Registry

https://doi.org/10.1016/j.healun.2019.07.001Get rights and content

BACKGROUND

Cardiac retransplantation accounts for approximately 3% of cardiac transplantation and is considered a risk factor for increased mortality. However, factors inherent to retransplantation including previous sternotomy, sensitization, and renal dysfunction may account for the increased mortality. We assessed whether retransplantation was associated with all-cause mortality after adjusting for such patient risk factors.

METHODS

We conducted a retrospective cohort study of adult and pediatric patients enrolled in the United Network for Organ Sharing database. We identified patients undergoing cardiac retransplantation based on transplant listing diagnosis and history of previous transplant. We used propensity-score matching to identify a matched cohort undergoing initial heart transplantation.

RESULTS

In total, 62,112 heart transplant recipients were identified, with a mean age 46.6 ± 19.1 years. Of these, 2,202 (3.4%) underwent late cardiac retransplantation (>1 year after initial transplant and not for acute rejection). Compared with a matched group of patients undergoing initial heart transplantation, patients undergoing late retransplantation had comparable rates of all-cause mortality at 1 year (13.6% vs 13.8%, p = 0.733). In addition, overall mortality was not significantly different after matching (unadjusted hazard ratio [HR] 1.08, p = 0.084). In contrast, patients undergoing retransplantation within 1 year of initial transplant or for acute rejection remained at increased risk of mortality post-transplant after similar matching (unadjusted HR 1.79, p < 0.001).

CONCLUSIONS

After matching for comorbidities, late retransplantation in the adult population was not associated with an increase in all-cause mortality. Our findings highlight the importance of assessing indication acuity and comorbid conditions when considering retransplant candidacy.

Section snippets

Study design and population

This was a retrospective cohort study of adult and pediatric patients enrolled in the United Network for Organ Sharing (UNOS) database between January 1996 and November 2017. Patient inclusion and exclusions are outlined in Supplementary Figure S1 (available online at www.jhltonline.org/). Patients who did not have follow-up status recorded in the database and those in whom a listing diagnosis was not recorded were excluded. Patients undergoing combined heart-lung transplantation were also

Results

In total, 62,112 patients were identified in the UNOS heart transplant database, of which 2,202 (3.5%) underwent late cardiac retransplantation at a median of 9.4 years (IQR 5.7–14.0 years) after initial transplant. An additional 349 (0.6%) patients underwent early/acute retransplant at a median of 154 days (IQR 4–322 days). Time to retransplantation for both groups are outlined in Figure 1. Median follow-up was 5.0 years (IQR 1.7–9.6 years), with slightly shorter follow-up in patients

Discussion

In this analysis of the UNOS heart transplant database, late retransplantation was not associated with an increased risk of all-cause mortality in the adult population after adjusting for donor and recipient characteristics previously identified as independently associated with mortality by the SRTR. In contrast, retransplantation within 1 year or for acute rejection was associated with increased all-cause mortality. These results suggest that the nuances of timing and acuity of

Conclusions

After matching for important donor and recipient characteristics, late retransplantation was not associated with increased all-cause mortality or need for retransplantation in the adult population. In contrast, retransplantation within 1 year or for acute rejection was associated with increased all-cause mortality. Our results highlight the importance of assessing indication acuity and comorbid conditions when assessing retransplant candidacy.

Disclosure statement

This work was supported in part by Health Resources and Services Administration contract 234-2005-370011C. The content is the responsibility of the authors alone and does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government. Dr Miller receives funding support from the Arthur J.E. Child Fellowship grant.

Supplementary data

Supplementary data associated with this article can be found in the online version at www.jhltonline.org/.

References (29)

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