The Western Thoracic Surgical Association

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Impact of Surgical Factors on Mortality Following Cardiac Transplantation
Andrea L Axtell, Amy G Fiedler, Elbert E Heng, David A D'Alessandro, Gregory Lewis, Erin Coglianese, Serguei Melnitchouk, George Tolis, Duke E Cameron, Mauricio A Villavicencio
Massachusetts General Hospital, Boston, MA

Background:
Early outcomes of cardiac transplantation in patients with a ventricular assist device (VAD) are worse than primary transplants. However, the individual risks and overall survival imposed by a prior sternotomy, VAD implantation, retransplantation, or radiation have not been independently compared and analyzed.
Methods:
Using the UNOS database, a retrospective cohort analysis was performed on the 27,380 adult patients who received a heart transplant in the US between 2000 and 2017. 10,192 patients (37%) had a primary operation, 5,883 patients (21%) had prior sternotomy, 10,483 patients (38%) had a VAD placement, 770 patients (3%) had a previous cardiac transplant, and 52 (0.1%) had a history of thoracic radiation. Kaplan Meier survival was compared between groups and further analyzed using a Cox proportional hazards regression model.
Results:
On unadjusted analysis, five and ten year mean survival rates were 80% (95% CI: 78-80%) and 62% (60-63%) for the primary transplant group, 76% (75-77%) and 58% (55-60%) for both the prior sternotomy and VAD groups, 69% (65-73%) and 51% (46-56%) for the retransplant group, and 51% (33-66%) and 45% (27-62%) for patients with radiation. Compared to primary transplants, all groups (prior sternotomy, VAD, retransplant, radiation) had worse five-year survival (all p<0.05), but there was no significant difference in five-year survival among the prior sternotomy, VAD, and retransplant groups (all p>0.05). On multivariable analysis, the survival difference at 5 years persisted, with reoperative sternotomy and radiation showing higher risk of death compared to primary transplants (prior sternotomy alone: HR 1.11 [1.04-1.19], p=0.001; VAD: HR 1.21 [1.12-1.30], p<0.001; retransplant: HR 1.40 [1.22-1.61], p<0.001; radiation HR 2.21 [1.41-3.46], p=0.001). The survival disadvantage associated with reoperation was explained early postoperative mortality. When excluding patients who died in the first post-transplant year, there were no significant differences in overall survival between the primary transplant, prior sternotomy alone, VAD, and retransplant groups (all p>0.01).
Conclusions:
Prior sternotomy, VAD placement, prior transplantation, and radiation are risk factors for worse survival after cardiac transplantation, mainly due to higher first-year mortality. Radiation exposure confers the greatest risk of both early and long term mortality in this cohort. Conditional five year survival among one year survivors is not affected by these factors.


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