Single Centre Outcomes of Heart Re-Transplantation: A Matter of Indication?

Purpose Heart re-transplantation (HRT) is the definitive treatment for end stage cardiac allograft vasculopathy (CAV) and refractory primary graft dysfunction (PGD). According to the ISHLT registry, the median survival of patients who underwent HRT between 1982-2016 is 6.6 years and CAV was the indication for re-transplantation in 44% of patients re-transplanted between 1982 and 2013. The objective of this study was to describe HRT outcomes from our Institution during the same period of time. Methods This is a retrospective cohort study including patients who had undergone HRT at Toronto General Hospital (TGH) or at Hospital for Sick Children and followed as adults at TGH from 1982 to 2019. Kaplan-Meier survival analysis was used to estimate median survival using date of HRT as index date. Results From January 1982 to September 2019, 592 patients were transplanted at TGH, and 92 transplanted in the pediatric age (0-18 years) were transitioned as adults. Of these, 16 (2.7%) adults (1986-2019) and 8 (8.7%) pediatric patients (1996-2006) underwent 26 HRTs (2 were transplanted 3 times). The median age at time of HRT was 47.8 (IQR 41.5-51.9) and 8.7 (IQR 5.1-15.4) years in adult and pediatric patients, respectively. Indications for HRT were CAV in 22 (84.6%), PGD in 2 (7.7%), and surgical reasons in 2 (7.7%). The median time between first and second transplant was 8.3 (IQR 3.2-11.3) years in adults, and 3.5 (IQR 0.3-9.7) years in pediatrics. Within a median follow up time of 7.7 years, 12 patients died: 4 from PGD. Overall median survival was 12.2 years (95% CI 8.5-15.9). When considering only patients re-transplanted as adults, the median survival was 10.1 years (95% CI 2.2-18.1). Younger age at HRT (HR 1.04, 95% CI 1.01-1.08, p= 0.008) was the only predictor of survival. Conclusion With CAV being the indication for re-transplantation in 85% of our patients, our single centre experience shows that HRT outcomes are better than those globally reported during the same period of time.