Prognosis after cardiac transplantation
- Michael X Pham, MD, MPH
Michael X Pham, MD, MPH
- Clinical Associate Professor of Medicine
- Stanford University School of Medicine
Cardiac transplantation remains the treatment of choice for many patients with end-stage heart failure (HF) with severely impaired functional capacity despite optimal medical therapy. Although barriers to long-term survival remain, the outcome among transplant recipients has improved over several decades as a result of careful recipient and donor selection, advances in immunosuppression, and the prevention and treatment of opportunistic infections. (See "Overview of the therapy of heart failure with reduced ejection fraction" and "Indications and contraindications for cardiac transplantation in adults".)
Current survival in adults after orthotopic heart transplantation, retransplantation, and combined organ transplantation will be reviewed here. The data presented are contained in the Adult Heart Report from the Registry of the International Society for Heart and Lung Transplantation (ISHLT), published annually [1-3]. Additional information regarding the indications for cardiac transplantation and treatment following transplantation is presented separately. (See "Indications and contraindications for cardiac transplantation in adults" and "Induction and maintenance of immunosuppressive therapy in cardiac transplantation" and "Acute cardiac allograft rejection: Diagnosis" and "Acute cardiac allograft rejection: Treatment".)
OUTCOME AFTER FIRST HEART TRANSPLANTATION
The most comprehensive information regarding patient survival after thoracic organ transplantation comes from data collected by the International Society for Heart and Lung Transplantation (ISHLT). This database includes data from over 100,000 cardiac transplants performed worldwide since 1982 by more than 380 transplant programs. Although center-specific data may vary, survival figures from data like the ISHLT registry are often quoted when providing patients with realistic expectations regarding survival after transplantation. For additional information, see http://www.ishlt.org/registries/slides.asp?slides=heartLungRegistry.
Survival — In a registry report, the median survival for adult and pediatric heart transplants performed between 1982 and June 2013 was 11 years . Patient survival has steadily improved since the 1980s, with one-year survival rates now exceeding 85 percent for patients transplanted in the most current era (2009 through June 2013). The major survival gains are limited to the first 6 to 12 months, with a long-term attrition rate of 3.4 percent per year thereafter, remaining largely unchanged. The improvement is probably larger than it appears, since the risk profile of recipients and the age of donors continue to increase.
Determinants of prognosis — A number of factors in the recipient and donor are associated with a worse prognosis post-transplantation.
- Stehlik J, Edwards LB, Kucheryavaya AY, et al. The Registry of the International Society for Heart and Lung Transplantation: Twenty-eighth Adult Heart Transplant Report--2011. J Heart Lung Transplant 2011; 30:1078.
- Lund LH, Edwards LB, Kucheryavaya AY, et al. The registry of the International Society for Heart and Lung Transplantation: thirty-first official adult heart transplant report--2014; focus theme: retransplantation. J Heart Lung Transplant 2014; 33:996.
- Lund LH, Edwards LB, Kucheryavaya AY, et al. The Registry of the International Society for Heart and Lung Transplantation: Thirty-second Official Adult Heart Transplantation Report--2015; Focus Theme: Early Graft Failure. J Heart Lung Transplant 2015; 34:1244.
- Barge-Caballero E, Segovia-Cubero J, Almenar-Bonet L, et al. Preoperative INTERMACS profiles determine postoperative outcomes in critically ill patients undergoing emergency heart transplantation: analysis of the Spanish National Heart Transplant Registry. Circ Heart Fail 2013; 6:763.
- Potapov EV, Loebe M, Hübler M, et al. Medium-term results of heart transplantation using donors over 63 years of age. Transplantation 1999; 68:1834.
- Marelli D, Laks H, Fazio D, et al. The use of donor hearts with left ventricular hypertrophy. J Heart Lung Transplant 2000; 19:496.
- Jeevanandam V, Furukawa S, Prendergast TW, et al. Standard criteria for an acceptable donor heart are restricting heart transplantation. Ann Thorac Surg 1996; 62:1268.
- Fishman JA, Rubin RH. Infection in organ-transplant recipients. N Engl J Med 1998; 338:1741.
- Montoya JG, Giraldo LF, Efron B, et al. Infectious complications among 620 consecutive heart transplant patients at Stanford University Medical Center. Clin Infect Dis 2001; 33:629.
- Srivastava R, Keck BM, Bennett LE, Hosenpud JD. The results of cardiac retransplantation: an analysis of the Joint International Society for Heart and Lung Transplantation/United Network for Organ Sharing Thoracic Registry. Transplantation 2000; 70:606.
- Groetzner J, Kaczmarek I, Mueller M, et al. Freedom from graft vessel disease in heart and combined heart- and kidney-transplanted patients treated with tacrolimus-based immunosuppression. J Heart Lung Transplant 2005; 24:1787.
- Raichlin E, Kushwaha SS, Daly RC, et al. Combined heart and kidney transplantation provides an excellent survival and decreases risk of cardiac cellular rejection and coronary allograft vasculopathy. Transplant Proc 2011; 43:1871.
- Cassuto JR, Reese PP, Bloom RD, et al. Kidney transplantation in patients with a prior heart transplant. Transplantation 2010; 89:427.
- Te HS, Anderson AS, Millis JM, et al. Current state of combined heart-liver transplantation in the United States. J Heart Lung Transplant 2008; 27:753.
- OUTCOME AFTER FIRST HEART TRANSPLANTATION
- Determinants of prognosis
- - Recipient factors
- - Donor factors
- - Patients undergoing mechanical circulatory support as a bridge to transplant
- - Late mortality
- Causes of death
- Repeat cardiac transplantation
- HEART-LUNG TRANSPLANTATION
- HEART-KIDNEY TRANSPLANTATION
- HEART-LIVER TRANSPLANTATION
- MEDICAL CONDITIONS AFTER CARDIAC TRANSPLANTATION THAT MAY AFFECT OUTCOME
- QUALITY OF LIFE AFTER TRANSPLANTATION
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS