Ten-year experience with extended criteria cardiac transplantation

Abstract

Background: Extended criteria cardiac transplant (ECCT) programs expand the transplant pool by matching donors and recipients typically excluded from the transplant process because of age or comorbidity. There is a paucity of data examining long-term outcomes with this strategy.

Methods and results: Between January 2000 and December 2009, adult patients undergoing isolated heart transplant were prospectively classified as ECCT based on prespecified criteria. Baseline characteristics and outcomes were compared between ECCT and standard criteria cardiac transplant recipients. Two Cox proportional hazards models were developed. The first to identify clinical variables contributing to survival between the 2 groups, and the second to determine the additional risk associated with assignment to ECCT. Among the 454 patients who underwent heart transplant, 84 (18.5%) were ECCT. Compared with the patients who underwent standard criteria cardiac transplant, ECCT patients were older (median, 66.6 years versus 53.2 years; P<0.001), with higher frequency of diabetes mellitus (46.4% versus 24.6%; P<0.001) and chronic kidney disease (median estimated glomerular filtration rate, 55 versus 61.6 mL/min; P=0.001). After adjustment for baseline characteristics, standard criteria cardiac transplant survival was higher than ECCT at 1 (89% versus 86%; P=0.18) and 5 (77% versus 66%; P=0.035) years. In a multivariate model that included listing criteria, creatinine (hazard ratio, 1.05 per 0.1 mg/dL; 95% confidence interval, 1.02-1.09; P=0.001) was a significant predictor of post-transplant mortality.

Conclusions: ECCT is an acceptable alternative for advanced heart failure therapy in select patients. Age and renal dysfunction are important determinants of long-term survival and post-transplant morbidity.

Keywords: heart failure; survival; transplantation.

Figure 1. Unadjusted Kaplan-Meier curves presenting estimated survival probabilities for each listing criteria over time

*P-value is determined based on the unadjusted hazard ratio estimated in a proportional hazards model.

Figure 2. Adjusted Kaplan-Meier Survival Curves by Listing Criteria

*P-value is determined based on the hazard ratio estimated in a proportional hazards model, adjusted for baseline variables.