Changes in patient characteristics following cardiac transplantation: the Montreal Heart Institute experience

Abstract

Background: Heart transplantation is no longer considered an experimental operation, but rather a standard treatment; nevertheless the context has changed substantially in recent years owing to donor shortage. The aim of this study was to review the heart transplant experience focusing on very long-term survival (≥ 20 years) and to compare the initial results with the current era.

Methods: From April 1983 through April 1995, 156 consecutive patients underwent heart transplantation. Patients who survived 20 years or longer (group 1) were compared with patients who died within 20 years after surgery (group 2). To compare patient characteristics with the current era, we evaluated our recent 5-year experience (group 3; patients who underwent transplantation between 2010 and 2015), focusing on differences in terms of donor and recipient characteristics.

Results: Group 1 (n = 46, 30%) included younger patients (38 ± 11 v. 48 ± 8 yr, p = 0.001), a higher proportion of female recipients (28% v. 8%, p = 0.001) and a lower prevalence of ischemic heart disease (42% v. 65%, p = 0.001) than group 2 (n = 110, 70%). Patients in group 3 (n = 54) were older (52 ± 12 v. 38 ± 11 yr, p = 0.001), sicker (rate of hospital admission at transplantation 48% v. 20%, p = 0.001) and transplanted with organs from older donors (42 ± 15 v. 29 ± 11 yr, p = 0.001) than those in group 1.

Conclusion: Very long-term survival ( ≥ 20 yr) was observed in 30% of patients transplanted during the first decade of our experience. This outcome will be difficult to duplicate in the current era considering our present population of older and sicker patients transplanted with organs from older donors.

Fig. 1

Kaplan–Meier curve for survival after cardiac transplantation for patients operated between 1984 and 1995. Patient survival at 1, 5, 10, 15 and 20 years averaged 84% ± 3%, 76% ± 3%, 69% ± 4%, 49% ± 4% and 35% ± 4%, respectively. The number of patients at risk is shown at the bottom of the graph.

Fig. 2

Freedom from cancer after cardiac transplantation. The freedom rate from cancer averaged 82% ± 6% and 61% ± 7%, respectively, 10 and 20 years after transplantation in group 1 patients compared with 64% ± 6% and 30% ± 9%, respectively, in group 2. The difference was significant using the log-rank test (p = 0.005).

Fig. 3

Freedom from development of graft vasculopathy. The freedom rate from allograft vasculopathy (also called chronic rejection), defined by any coronary artery lesions at planned and unplanned coronary angiography, averaged 44% ± 7% and 39% ± 7%, respectively, 10 and 15 years after transplantation in patients of group 1 compared with 46% ± 6% and 36% ± 6%, respectively, in group 2 patients. The difference was not significant (p = 0.96).