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Ann Thorac Surg 2003;75:1878-1885
© 2003 The Society of Thoracic Surgeons

Original article: cardiovascular

Does the pretransplant UNOS status modify the short- and long-term cardiac transplant prognosis?

Olivier Baron, MDa*, Alexandre Le Guyader, MDa, Jean Noël Trochu, MDa, Marc Burban, MDa, Jean Christophe Chevalier, MDa, Michelle Treilhaud, MDa, Thierry Petit, MDa, Oussama Al Habash, MDa, Philippe Despins, MDa, Jean Luc Michaud, MDa, Daniel Duveau, MDa

a Unité de Transplantation Thoracique, Service de Chirurgie Thoracique et Cardiovasculaire, Hôpital G et R Laënnec, Nantes, France

Accepted for publication January 17, 2003.

* Address reprint requests to Dr Baron, Unité de Transplantation Thoracique, Service de Chirurgie Thoracique et Cardiovasculaire, Hôpital G et R Laënnec, 44093 Nantes, France.
e-mail: olivier.baron{at}chu-nantes.fr


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Comment
 Acknowledgments
 References
 
BACKGROUND: We compared the morbidity and mortality rates of patients who had urgent heart transplantation or transplantation after bridging with a ventricular assist device, with the rates of patients whose clinical stability allowed them to wait at home.

METHODS: From March 1985 to December 2000, 404 patients underwent heart transplantation in a single center. There were 273 patients with UNOS status 2 (US 2), 103 patients with UNOS Status 1A (US 1A), and 28 patients with UNOS Status 1B (US 1B). We compared the groups retrospectively with respect to pretransplantation status and operative results.

RESULTS: Despite more severely impaired hemodynamics and a significantly higher preoperative infection rate in US 1A and 1B patients, there were no statistically significant differences in survival rates among the three groups. Donor sex and age, cytomegalovirus and toxoplasmosis, mismatch rate, ischemic time, method of myocardial protection, and operative technique did not differ statistically among the three groups. Length of intensive care unit stay, postoperative morbidity, first year postoperative rejection rate, and graft occlusive vascular disease rate were statistically similar among the three groups. Although pretransplantation cancer assessment was less complete in US 1A and 1B than in US 2 patients, the late-cancer rate was not statistically different among the three groups.

CONCLUSIONS: These data suggest that urgently transplanted patients have both early and long term morbidity and mortality similar to those of patients waiting for transplantation at home or with a ventricular assist device.


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Comment
 Acknowledgments
 References
 
Despite recent progress in the medical treatment of heart failure, mortality rates remain high in patients with New York Heart Association stage III and IV disease. Almost 40% are dead 2 years, and more than 70% are dead 6 years after diagnosis [1]. In patients with New York Heart Association stage IV heart failure, the annual mortality rate is about 50% [2]. Heart transplantation contributes to both functional improvement and survival. In our center, the survival of the first 281 transplanted patients was 87% at 1 year, 77% at 5 years, and 57% at 10 years. Age younger or older than 60 years did not affect survival [3].

Because donor organs are in increasingly short supply, wait lists are becoming longer. More urgent admissions for transplant patients requiring inotropic support has led to an increase in urgent transplant operations. This, in turn, has required even more rigorous selection criteria, increasing the pressure towards bridging by ventricular assist devices, which might increase transplantation morbidity and mortality rates [4]. The purpose of this retrospective study was to compare the morbidity and mortality rates among patients who had urgent heart transplantation with those who had implantation of bridging devices and those who waited at home for elective transplantation.


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Comment
 Acknowledgments
 References
 
Study population
Between March 1985 and December 2000, 404 patients had heart transplantation, of whom 6 had retransplants. The following three groups were defined according to the following UNOS status [5] categories: status 1A, critically ill patients requiring continuous inotropic drug therapy or mechanical assistance and who have a life expectancy of less than 1 month without transplantation; status 1B, medically stable patients requiring mechanical assistance who have a life expectancy greater than 1 month (assisted circulation became available in our center in 1988); and status 2, patients with chronic heart failure who do not meet the higher urgency criteria for status 1A or 1B.

The decision to change from inotropic support (US 1A) to mechanical support (US 1B) was based on continuous clinical, echocardiographic, hemodynamic (cardiac index, pulmonary artery pressure, and oxygen mixed venous saturation), and biochemical (creatinine, bilirubin, and blood lactate level) evaluation of each unstable patient hospitalized in an intensive care unit next to the cardiac surgery department.

Patients were characterized by age, sex, type of heart disease, history of cardiac operations, obesity, history of renal insufficiency requiring dialysis, diabetes, neoplasm, serious infection, and presence or absence of complete pretransplantation cancer assessment. We noted the presence of donor seropositivity and recipient seronegativity for cytomegalovirus (CMV) and toxoplasmosis. Preoperative hemodynamic data consisted of mean pulmonary artery pressure, pulmonary capillary wedge pressure, pulmonary vascular resistance, and cardiac index. Transplantation waiting time was defined as the interval between placement on the waiting list and the day of transplantation. Transplant quality criteria were defined by the donor’s age and heart ischemia time. Cardiopulmonary bypass time was recorded.

Patients were excluded as candidates for transplantation according to generally accepted criteria [6]. Absolute contraindications were (1) pulmonary hypertension with pulmonary vascular resistances higher than 6 Wood units (WU) and remaining higher than 3.5 WU after pharmacologic tests (Enoximone, vasodilators, and nitric oxide test), (2) neoplastic disease during the previous 5 years, (3) recent uncontrolled infection, or (4) other severe organ failure. According to their degree of severity, relative contraindications were insulin-dependent diabetes mellitus, renal or hepatic insufficiency, and pulmonary disease.

Transplant technique
The operative technique, chosen by preference of the operator, was total or subtotal cardiectomy in 215 patients (53.2%) and the Stanford technique in the other 189 patients (46.8%). The donor heart was preserved with Bretschneider solution in 264 patients (65.4%) and Celsior solution in 140 patients (34.6%). Immunosuppressive therapy was the same in the three groups and consisted of antilymphocyte globulins for 3 to 5 days followed by a combination of cyclosporine, corticosteroids, and azathioprine, and, more recently, by mycophenolate mofetil or tacrolimus. Patients underwent endomyocardial biopsy weekly for 6 weeks after transplantation, then every 2 weeks until the third month, and then every 6 weeks until the 6 month. Biopsies were also performed at the ninth month, the 12th month, and then yearly. Rejection severity was grade 0 to 4 according to the International Society for Heart and Lung Transplantation grading system. Grade 2 was managed with an increase in oral steroids or cyclosporine. Intravenous bolus steroid therapy (500 mg/day x 5 days) was given for grade 3A or greater. If a follow-up biopsy performed 10 days thereafter showed no improvement, antilymphoblast globulin was administered. Coronary angiography was performed every other year to monitor transplant coronary disease.

Postoperative data
We recorded postoperative infections, reoperations, total hospital stay (in the intensive care unit and in the ward before hospital discharge), number of episodes of treated acute rejection (at least grade IB according to the International Classification), and the incidences of cancer and transplant coronary artery disease. Survival curves were established from overall mortality, including operative mortality.

Statistical analyses
To calculate differences between groups, we used a {chi}2 test for comparison of qualitative and discrete numerical variables. A Kruskall-Wallis test was used for multiple comparisons of quantitative variables among the three groups, and a Mann-Whitney test was used to identify the differences among the groups

To calculate the mortality rate within each group, the factors associated with both in-hospital and late mortality were assessed first by univariate analysis using Fischer’s exact test and the Mann-Whitney test when appropriate. A second evaluation by logistic regression analysis included variables with p less than 0.1 in the univariate analysis.

The overall mortality rate was analyzed by the Kaplan-Meier method. A log-rank test was performed to compare probabilities when possible. A Cox model was used to test the role of covariates. A proportional hazard model was fit to the observed data using the variables extracted from the univariate analysis as covariates, with the three UNOS status groups to stratify the model. The natural logarithm of the cumulative base line hazards plots for UNOS status was examined to look for the parallelism of the three curves (ie, indicating the proportionality of the hazard functions when the covariates were included). When the proportionality was assumed to be present, the UNOS status was reassigned as a covariate. In the absence of proportionality, the analysis was stopped and no conclusion could be drawn. After the analysis, the relative hazards were estimated.


   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Comment
 Acknowledgments
 References
 
Population
In the US 2 group, there were 273 patients (67.6%), of which 234 were male and 39 female. The mean age was 51 ± 11 years (range, 12 to 67 years). The mean waiting time before transplantation was 66 ± 68 days.

In the US 1A group, there were 103 patients (25.5%) who were waiting for transplant in the hospital and were given (separately or in combination) inotropic drugs, intraaortic balloon pump, or centrifugal pump (Biomedicus). There were 91 men and 12 women, and the mean age was 47 ± 15 years (range, 12 to 66 years). The mean waiting time before transplantation was 23 ± 29 days. An indication for urgent heart transplantation was decided in 42 patients (40.8%) who were already waiting for transplantation but also in 61 (59.2%) new patients who presented with a first episode of acute decompensation from heart disease. Indications included heart failure refractory to maximum medical treatment in 79 cases (76.7%), rhythmic instability with severe arrhythmias in 23 (22.3%), and unstable ischemia in 1 (1%). Eighty-five of these patients were treated with dobutamine (82.5%), which was associated with Enoximone in 52 patients (50.5%) and intraaortic balloon pump in 9 patients (8.7%). Four patients were treated with a Biomedicus centrifugal pump (3.9%) for a mean of 8 days (range, 3 hours to 11 days). Three of these patients required left ventricular assistance, and one required biventricular ventricle assistance.

In the US 1B group, there were 28 patients (6.9%) who had long-term ventricular assistance (16 Cardiowest, 7 Novacor, 5 double Thoratec) with a mean waiting time of 69 ± 65 days to transplantation. All these patients were male with a mean age of 41 ± 11 years (range, 16 to 61 years). Twenty-two (78.6%) presented with a first episode of acute decompensation of heart disease (myocardial infarction, rapid destabilization of dilated cardiomyopathy), and the possibility of transplantation had not been previously proposed.

Table 1 summarizes the preoperative data. Patients in US 1B were younger than those in US 1A and US 2, but sex distribution, initial heart disease, and medical history did not differ among the three groups. The pretransplantation cancer assessment was more often incomplete in US 1A (43.7%) and US 1B (60.7%) than in US 2 (1.8%) (p < 0.001 between US 2 and US 1A or 1B). At least one preoperative infection was identified in 1.1% of patients in US 2, 29.1% in US 1A, and 57.1% in US 1B (p < 0.0001 between US 2 and US 1A or 1B; p < 0.05 between US 1A and 1B).


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  		Table 1. Preoperative Characteristics

 
The waiting time to transplant was significantly shorter in US 1A (23 ± 29 days versus 66 ± 68 days in US 2 and 69 ± 65 days in US 1B).

Preoperative hemodynamic variables
Mean pulmonary artery pressure (mm Hg) was 29 ± 10, 33 ± 9, and 34 ± 9 for US 2, 1A, and 1B, respectively (p < 0.001 US 2 versus 1A; p < 0.05 US 2 versus 1B; and p > 0.05 between US 1A and 1B). Pulmonary capillary wedge pressure (mm Hg) was 20 ± 9, 23 ± 8, and 25 ± 8 for US 2, 1A, and 1B, respectively (p < 0.001 US 2 versus 1A; p < 0.05 US 2 versus 1B; and p > 0.05 between US 1A and 1B). Cardiac index (l · min-1 · m-2) was 2.22 ± 0.75, 2.11 ± 1.8, and 2.05 ± 0.64 for US 2, 1A, and 1B, respectively (p > 0.05 between groups). Pulmonary vascular resistance (WU) was 2.44 ± 1.3, 2.9 ± 1.8, and 2.6 ± 1.8 for US 2, 1A, and 1B, respectively (p > 0.05 between groups).

Transplant
No statistically significant differences were found between US 2, 1A, and 1B, respectively, for donor’s age (years) (30 ± 10, 29 ± 10, and 27 ± 10), donor’s sex (M/F) (215/58, 82/2, and 24/4), transplant ischemia time (minutes) (157 ± 43,166 ± 48, and 166 ± 40), CMV mismatches (16.1%, 13.6%, and 21.4%), and toxoplasmosis mismatches (9.1%, 11.6%, and 10.7%). Cardiopulmonary bypass time (minutes) was 112 ± 29, 113 ± 29, and 146 ± 70 for US 2, 1A, and 1B, respectively (p = 0.001 US 2 versus 1B; p = 0.008 US 1A versus 1B; and p > 0.05 between US 2 and 1A).

Hospital morbidity rate and length of stay
No statistically significant differences were found among US 2, 1A, and 1B, respectively, for tamponade, hemorrhage requiring drainage operations (23.4%, 18.4%, and 14.3%, respectively), presence of right heart failure (21.6%, 18.4%, and 7.1%, respectively), renal failure requiring dialysis (4.7%, 3.9%, and 3.7%, respectively), and incidence of acute rejection episodes (0.7%, 1.9%, and 3.5%, respectively). Mean intensive care unit and total hospital length-of-stay were comparable (9.3 ± 5.7 days and 32.1 ± 12 days for US 2; 9.5 ± 7 days and 32.5 ± 12.8 days for US 1A; and 8.8 ± 6.3 days and 37.1 ± 13 days for US 1B, respectively).

Infections
Thirty (29.1%) of the 103 patients in US 1A and 16 (57.1%) of the 28 patients of US 1B had been treated for at least one infection before transplantation. These infections had been controlled by appropriate antibiotics and did not represent a contraindication to transplantation. Postoperative infections also developed in 9 patients in US 1A (8.7%) , four of which were caused by the same organism isolated preoperatively. Postoperative infection also developed in 5 patients in US 1B (17%). Seven (25%) patients in US 1B had an infection related to the ventricular assist device (power supply, Novacor abdominal pouch). None of these infections were responsible for posttransplantation complications. Three (1.1%) patients in US 2 with preoperative infection had a different infection after transplantation.

The posttransplantation infection rate was not significantly different among the three groups (96 patients in US 2 [35.1%], 39 patients in US 1A [37.8%], and 12 patients in US 1B [42.8%]). Table 2 shows the etiologies of infections before and after transplantation. Toxoplasma infections occurred in 1 patient with positive pretransplantation serology and in 2 seronegative patients grafted with a seropositive donor.


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  		Table 2. Etiologies of Infections Before and After Transplantation

 
Seven patients (1.7%) died during the postoperative period, 6 from septic shock (bacterial septicemia in 5 and Aspergillus septicemia in 1) and 1 from myocardial toxoplasmosis.

Episodes of acute rejection per patient
The number of acute rejection episodes per patient was 1.4 ± 1.4, 1.3 ± 1.3, and 1.3 ± 1.2 for the first posttransplantation year for US 2, 1A, and 1B, respectively. In years following the first, the number of acute rejection episodes per patient was 0.17 ± 0.7, 0.13 ± 0.4, and 0.11 ± 0.1 for US 2, 1A, and 1B, respectively. There were no significant differences among groups for either period.

Cancer
There were 68 patients in US 2 (24.9%) who developed at least one cancer after transplantation (mean posttransplant interval, 56.2 ± 34.2 months), compared with 22 patients in US 1A (21.3%) after a mean interval of 62.1 ± 47.4 months, and 3 patients in US 1B (10.7%) after a mean interval of 72.6 ± 59.7 months. Kaplan-Meier cancer-free survival curves are shown in Figure 1. No statistically significant difference was observed among the three groups. Table 3 summarizes the types of cancers. Squamous cell carcinomas, adenocarcinomas, and lymphomas were the three most frequent diagnoses. Some patients had recurrent cutaneous carcinomas. A patient with surgically treated carcinoma of the colon, thought to be tumor-free by pretransplant assessment, had recurrent carcinoma 52 months after transplantation.



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  		Fig 1. Kaplan-Meier cancer-free survival curves. US = UNOS status.

 

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  		Table 3. Etiologies of Cancers After Transplantation

 
Transplant coronary artery disease
Kaplan-Meier transplant coronary artery disease-free survival curves are shown in Figure 2. No statistically significant difference was found between the three groups. Transplant coronary artery disease-free survival at 6 years was 81.2% ± 3%, 75.5% ± 6%, and 61% ± 5% for US 2, 1A, and 1B, respectively.



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  		Fig 2. Kaplan-Meier transplant coronary artery disease-free survival curves. US = UNOS status.

 
Operative and Long-Term mortality rates
The in-hospital mortality rate was 7.7%, 7.8%, and 17.8% for US 2, 1A, and 1B, respectively, with no statistically significant differences among the groups. The causes of early deaths are listed in Table 4. Univariate analysis demonstrated that ischemic heart disease (p = 0.048), cardiopulmonary bypass time (p = 0.008), postoperative acute rejection (p < 0.001), and right heart failure (p = 0.002) in US 2; cardiopulmonary bypass time (p = 0.048) and postoperative acute rejection (p = 0.003) in US 1A; and postoperative acute rejection (p < 0.001) in US 1B were the only variables associated with increased operative mortality. Using multivariate analysis, right heart failure (p = 0.005; odds ratio [OR] = 0.76 with 95% confidence interval [CI] = 0.85 to 0.67) was the only variable associated with increased mortality in US 2, and no variables were associated with increased operative risk in the two other groups.


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  		Table 4. Causes of In-Hospital Death

 
The causes of long-term mortality are listed in Table 5. Univariate analysis demonstrated an association between long-term mortality and donor’s age (p = 0.035), preoperative pulmonary artery pressure (p = 0.042), transplant ischemia time (p = 0.008), numerous episodes of acute rejection during and after the first postoperative year (p = 0.025 and 0.021, respectively), the rate of cancer (p < 0.001), and the disease-free interval between transplantation and cancer (p = 0.04) in US 2; the rate of cancer (p < 0.001), numerous episodes of acute rejection during the first postoperative year (p < 0.001), and recipient’s age (p = 0.043) in US 1A; and transplant ischemia time (p = 0.049) in US 1B. Using multivariate analysis, variables associated with long-term mortality were donor’s age (p = 0.035; OR = 0.909; CI = 0.83 to 0.99) and the rate of cancer (p = 0.035, OR = 0.97; CI = 0.93 to 0.99) in US 2; numerous episodes of acute rejection during the first postoperative year (p = 0.001; OR = 10.3; CI = 2.6 to 40.4) and the rate of cancer (p = 0.013, OR = 4.46; CI = 1.4 to 14.4) in US 1A; and no variables associated with increased long-term mortality in US 1B.


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  		Table 5. Causes of Late Death

 
Long-term survival
Figure 3 shows the similarity of the Kaplan-Meier actuarial survival curves of groups US 1A, 1B, and 2. In those groups, the 1-year survival rate was, respectively, 89.7% ± 3.1%, 77.4% ± 8.1%, and 86.4% ± 2.1%; 3-year survival was 86.3% ± 3.5%, 77.4% ± 8.1%, and 82.7% ± 2.4%; 6-year survival was 81.4% ± 4.3%, 77.4% ± 8.1%, and 76.3% ± 2.8%; and 9-year survival was 71.5% ± 6.0%, 64.5% ± 13.6%, and 65.1% ± 3.7%.



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  		Fig 3. Kaplan-Meier actuarial annual survival in the three groups.

 
Cox model
Initially, age, transplant waiting time, and preoperative sepsis were used as covariates with UNOS groups to stratify the model. As illustrated in Figure 4, the curves were not parallel, and we could not therefore assume that the hazard functions for all three groups were proportional. The two curves representing US 2 and 1A, however, were approximately parallel, suggesting proportionality between hazard functions and the possibility of including group as a covariate in a model comparing US 2 with 1A. Consequently, we reassigned group as a covariate after excluding the patients in US 1B. The results showed that age was the only covariate that could affect the hazards significantly (p = 0.013; estimate = 0.032; standard error = 0.013).



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  		Fig 4. Kaplan-Meier estimation.

 

   Comment
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
Acknowledgments
 References
 
Despite poorer hemodynamics and fewer complete pretransplantation cancer assessments in patients in groups US 1A and US 1B, survival was comparable to that of stable patients awaiting elective transplantation (US 2), even as the proportion of patients in US 1A and 1B increased with time. In 1985, patients classified as US 1A or 1B comprised only 21.5% of our transplant recipients. By 2002, one third of our patients (32.4%) belonged to these higher-risk groups. The survival results reported here are similar to those of patients who have received a ventricular assist device while awaiting transplantation [7, 8]. Early experiences with urgent transplantation were associated with a 10% to 20% higher mortality rate at 1 year [9, 10], although differences in study populations, definitions, and endpoints make comparisons difficult. In the late 1980s, Loisance and colleagues [11] reported a 1-year survival rate of 52% in patients transplanted for refractory heart failure with pharmacologic or ventricular assistance bridge, compared with 76% in patients who were stable before transplantation. Stevenson and associates [12] reported a 1-month mortality rate of 12% in 50 patients who had urgent transplantation compared with 3% in 137 patients who had elective transplantation. The latest studies report survival rates of 86% at 1 year and 80% at 3 years in patients transplanted after a ventricular assist device bridge [7], a significant improvement over earlier results [8, 13]. The role of urgent heart transplantation or the use of a ventricular assist device bridge to transplantation remains controversial. In a series of 234 patients, univariate analysis showed that patients waiting for transplantation at home had a lower mortality rate than those hospitalized and requiring positive inotropic or ventricular assist device bridge [13]. Multivariate analysis demonstrated that increased pulmonary vascular resistance was an independent factor predictive of poor prognosis. Conversely, McCarthy and coworkers [8] showed that ventricular assist device bridge before transplantation was not a risk factor for mortality after transplantation. Another study found a lower (57%) 5-year survival rate in patients treated with a ventricular assist device bridge before transplantation, compared with patients waiting at home (78%) or those receiving medical treatment in the hospital (74%) [14].

Several factors can explain our results. We believe that the use of phosphodiesterase inhibitors, either alone or in combination with dobutamine and dopamine, and assisted circulation (introduced in 1988) has been important. Phosphodiesterase inhibitors, especially Enoximone, which was used in 52 of the 103 patients in US 1A (50.5%), provide a real medical bridge by means of their inotropic action on the myocardium together with a direct pulmonary and systemic vasodilator effect [15]. Pretransplantation use of phosphodiesterase also improves patient selection by determining the degree to which pulmonary hypertension is reversible.

In the treatment of cardiogenic shock, we have found that early institution of maximal inotropic support is more effective than a regimen of incremental increases in dosage. Furthermore, consideration of single or double ventricular mechanical support remains an option in the event of continued hemodynamic instability or deterioration. Timing is critical in the treatment of these patients, and the decision to replace purely medical treatment by assisted circulation must not be considered a last resort, but rather one of the available treatment options for heart failure while awaiting transplantation [16]. Since 1988, we have transplanted 28 patients after a bridge by assisted circulation (Thoratec, Novacor, or Cardiowest).

The decision to implant a ventricular assist device is based on several indices [17], including systemic blood pressure, hemodynamic surveillance by Swan-Ganz catheter, hourly diuresis, and laboratory surveillance of renal and liver function. Pifarre and colleagues [18] and Reedy and colleagues [19] found an improvement in 1-month and 1-year survival rates in patients transplanted after assisted circulation compared with their overall population of heart transplant recipients. In our series, the survival rate of patients transplanted after ventricular assist device was comparable to that of patients waiting at home. Massad and associates [20] reported similar results in a study of 53 urgently transplanted patients from a population of 256 transplant recipients.

In our series, cardiopulmonary bypass time was longer and operative mortality rate higher in US 1B than in US 2 or 1A, perhaps reflecting the presence of severe inflammatory adhesions associated with the presence of mechanical support devices. Of the five operative deaths in US 1B, three were encountered early in our Novacor and Thoratec experience. We have since learned to initiate cardiopulmonary bypass by femoral cannulation and to discontinue ventricular assist device pumping before sternotomy. Despite the increased operative risk, mechanical assistance appears to protect patients from posttransplant right ventricular failure (right heart failure was an operative mortality risk factor only in US 2). We conclude that the use of phosphodiesterase inhibitors and mechanical assist devices were protective of postoperative right ventricular function in groups 1A and 1B.

Hemodynamic stabilization allows a more complete pretransplantation assessment. In our series, however, 62 of the 131 patients transplanted urgently or after ventricular assist device implantation (47.3%) had incomplete pretransplantation assessment. Nevertheless, we did not later discover any cancers that could have been detected before transplantation. Postoperative infection continues to be a problem in transplantation, but we found no significant differences in incidence among the three groups. Although the waiting time was significantly shorter in the group of urgently transplanted patients, donor age and transplant organ ischemia time were comparable in the three groups. Because the supply of donor hearts is limited, we sometimes accept transplants from older donors, but there were no differences among the groups. The influence of the transplant ischemia time (greater than 240 minutes) on the results of transplantation is controversial [21, 22], and the use of transplants from older donors is responsible for an increased postoperative mortality [23].

Urgent transplantation or transplantation after bridging with a ventricular assist device did not have any influence on the surgical technique used or on postoperative complications requiring reoperation, although cardiectomy was longer and more difficult in patients who had circulatory assistance. There was no significant difference among the three groups with respect to the number of episodes of acute rejection during the first year and beyond. Preoperative hemodynamic instability and its consequences (renal insufficiency, sepsis) did not influence the quality of immunosuppression.

In our practice, the number of patients transplanted urgently or after bridging by ventricular assist device increases each year. Because the hospital morbidity and long-term survival rates in these patients are comparable to those of patients waiting at home, we are encouraged to continue this protocol. We emphasize the timely referral of patients in cardiogenic shock to a team experienced in assisted circulation techniques, should they become refractory to optimal medical treatment. Control of pretransplant nosocomial infection is obvious but necessary. The major practical obstacle to the growth of urgent transplantation is the decreasing availability of organs. The use of transplants from older donors may be inevitable, but it is likely to be associated with increased operative mortality rates. The more frequent application of assisted circulation as a bridge to transplantation is also inevitable because of longer waiting lists. Until a permanent implantable ventricular assist device becomes available, urgent transplantation or transplantation after temporary mechanical ventricular assistance provides acceptable results if candidates are chosen by carefully defined criteria.


   Acknowledgments
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 Acknowledgments
References
 
Many thanks to Dr Philippe Bizouarn for statistical assistance and advice. We are indebted to Dr Ronald Weintraub for his assistance in the preparation of this manuscript.


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 Acknowledgments
 References
 

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  4. Kaye M.P. Registry of the International Society for Heart and Lung Transplantation: tenth official report-1993. J Heart Lung Transplant 1993;4:541-548.
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  7. Tenderich G., Arusoglu L., El-Banayosy A., et al. Influence of different assist devices on survival after orthotopic heart transplantation. Int J Artif Organs 1999;22(11):764-768.[Medline]
  8. McCarthy J.F., McCarthy P.M., Massad M.G., et al. Risk factors for death after heart transplantation: does a single-center experience correlate with multicenter registries?. Ann Thorac Surg 1998;65(6):1574-1578.[Abstract/Free Full Text]
  9. Champagnac D., Claudel P., Chevalier P., et al. Primary cardiogenic shock during acute myocardial infarction: results of emergency cardiac transplantation. Eur Heart J 1993;14:925-929.[Abstract/Free Full Text]
  10. Dubois C., Dreyfus G., de Lentdecker P., et al. Transplantation cardiaque en urgence. Arch Mal Coeur 1996;89(VI):39-42.
  11. Loisance D., Hillion M.L., Deleuze P.H., et al. La transplantation cardiaque en super urgence. Arch Mal Coeur 1989;82:1421-1426.
  12. Stevenson L.W., Donohue B.C., Tillisch J.H., Schulman B., Dracup K.A., Laks H. Urgent priority transplantation: when should it be done?. J Heart Transplant 1987;6:267-272.[Medline]
  13. Kirsch M., Baufreton C., Naftel D.C., Benvenuti C., Loisance D. Pretransplantation risk factors for death after heart transplantation: the Henri Mondor experience. J Heart Lung Transplant 1998;17:268-277.[Medline]
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