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Etiology of Failure Predicts Heart-Lung Transplant Candidate's Waitlist Survival
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The Journal of Heart and Lung Transplantation, Vol 38, No 4S, April 2019
performed. Lobar venous blood gases taken during organ retrieval were used as guidance to determine which lobe was resected. Univariate analysis revealed no statistical significant difference in mortality between the trimming and the non-trimming group. Lung function tests between 6 and 12 months after transplantation revealed a median FEV of 90% (Min 42% Max 121%) in the non-trimming (NT) group versus 61% (Min 56% Max 97%) in the T group. The median FVC1 in the NT group was 94% (Min 40% Max 119%) versus 59% (Min 55% Max 116%) in the T group. The difference was not statistically significant. Conclusion: In summary, lung transplant volume reduction surgery either by anatomical or non-anatomical resection is a procedure that could offer results comparable to the conventional lung transplantation without additional morbidity or mortality. This strategy extends the lung donor pool, especially for the critically ill pediatric patients.
124 Etiology of Failure Predicts Heart-Lung Transplant Candidate’s Waitlist Survival K.W. Riggs,1 J.L. Chapman,1 M. Schecter,2 C. Towe,2 R. Bryant,1 F. Zafar,1 and D.L. Morales.1 1Cardiothoracic Surgery, Cincinnati Children's Hospital, Cincinnati, OH; and the 2Pulmonary Medicine, Cincinnati Children's Hospital, Cincinnati, OH. Purpose: Predictors of waitlist (WL) mortality for heart-lung transplant (HLT) has not previously been analyzed. We hypothesized that etiology of failure would be a predictor of mortality prior to receiving a HLT. Methods: Pediatric (<18yo) HLT candidates were identified within the UNOS database (1987-2018). Univariate logistical regression identified risk factors for six-month WL mortality to be included in multivariate analysis. Results: There were 604 HLT candidates identified, 34% (n=206) of whom were transplanted. Only 26% of patients received a transplant by 1 year on the WL with 30% dying. Median time to transplant was 131 days. Diagnoses were Primary Pulmonary Hypertension (IPAH) (n=142), Congenital Heart Disease (CHD) without Eisenmenger Syndrome (ES) (n=67), CHD with ES (n=74), and Other(n=321). Waitlist survival by diagnosis is displayed by Figure 1. There was no significant difference in wait time among the groups (p>0.05) and time on waitlist did not impact post-transplant survival for any diagnosis. On multivariate analysis (Table 1), risk factors for mortality at 6-months included a diagnosis other than CHD with ES (OR: 6.35, 95% CI: 1.9-21.2, p=0.003), IV inotropes (OR: 2.86, 95% CI: 1.585.18, p=0.001), and being an infant (OR: 2.44, 95% CI: 1.42-4.18, p=0.001). Conclusion: Diagnosis is the most important predictor of WL mortality in heart-lung transplantation. Despite similar waiting times to other diagnoses, patients with CHD with ES are the most likely to survive to HLT.
Risk factors for six-month pediatric heart-lung transplant waitlist mortality. Identified Risk Factors Odds Ratio (95% CI) p-value Diagnosis other than CHD with ES* IV Inotropes* Patient Age: Infant* 2-11 years old 12-17 years old Ventilator life support Diagnosis other than CHD without ES Non-Caucasian ECMO support
6.35* (1.9-21.19) 2.86* (1.58-5.18)
0.003* 0.001*
2.44* (1.42-4.18) 1.0 (0.62-1.63) Reference 1.89 (0.97-3.69) 1.44 (0.66-3.16) 1.44 (0.92-2.26) 1.37 (0.56-3.39)
0.001* 0.98 − 0.06 0.36 0.11 0.49
125 Is the Current Era Better for Pediatric Heart-Lung Transplantation? K.W. Riggs,1 J.L. Chapman,1 M. Schecter,2 C. Towe,2 R. Bryant,1 F. Zafar,1 and D.L. Morales.1 1Cardiothoracic Surgery, Cincinnati Children's Hospital, Cincinnati, OH; and the 2Pulmonary Medicine, Cincinnati Children's Hospital, Cincinnati, OH. Purpose: Pediatric heart-lung transplant (HLT) is known to have poor survival. We sought to define if there has been any improvement in pediatric HLT outcomes over time and if there is a cohort that portends better or worse survival. Methods: Pediatric (<18yo) HLT cases were identified within the UNOS database. The data was further divided into Era 1 (1987-1999) and Era 2 (2000-2018). Cox proportional hazard model was used to identify risk factors for post-transplant survival. Results: There has been a 30% drop in pediatric HLT in Era 2. ECMO at transplant has increased from 4% in Era 1 to 12% in Era 2. Similarly, PRA>10% (11.6% to 25.9%, p=0.01), and congenital heart disease (CHD) without Eisenmenger Syndrome (ES) (14% to 25.9%, p=0.03) have increased, whereas, CHD with ES has significantly decreased in Era 2 (23.1% to 9.4%, p=0.01). Two-year post-transplant survival has not changed between eras (p=0.99); however, two-year conditional survival has significantly increased (p=0.01) as shown in Figure 1. Patients on ECMO at transplant have a 7.9 times increased risk of mortality post-transplant (CI: 2.2-29.3, p=0.002). Infant (HR: 2.9, CI: 1.5-5.9, p=0.002) and 2-11 year old (HR: 1.7, CI: 1.0-2.7, p=0.037) patients also have an elevated risk of mortality post-transplant compared to adolescents. Only 13% (2/15) of ECMO patients survived beyond two years post-transplant with a median survival of 64 days, but in the current era, a patient not on ECMO has a median survival of nearly 3 years. Conclusion: Although the number of pediatric HLT has decreased significantly, the long-term outcomes continue to improve post-HLT. With a median post-transplant survival of 2 months for a patient on ECMO, we should be prudent about HLT since it adds little survival benefit. However, in a well selected cohort, HLT can add significant survival benefit.
The Journal of Heart and Lung Transplantation, Vol 38, No 4S, April 2019
performed. Lobar venous blood gases taken during organ retrieval were used as guidance to determine which lobe was resected. Univariate analysis revealed no statistical significant difference in mortality between the trimming and the non-trimming group. Lung function tests between 6 and 12 months after transplantation revealed a median FEV of 90% (Min 42% Max 121%) in the non-trimming (NT) group versus 61% (Min 56% Max 97%) in the T group. The median FVC1 in the NT group was 94% (Min 40% Max 119%) versus 59% (Min 55% Max 116%) in the T group. The difference was not statistically significant. Conclusion: In summary, lung transplant volume reduction surgery either by anatomical or non-anatomical resection is a procedure that could offer results comparable to the conventional lung transplantation without additional morbidity or mortality. This strategy extends the lung donor pool, especially for the critically ill pediatric patients.
124 Etiology of Failure Predicts Heart-Lung Transplant Candidate’s Waitlist Survival K.W. Riggs,1 J.L. Chapman,1 M. Schecter,2 C. Towe,2 R. Bryant,1 F. Zafar,1 and D.L. Morales.1 1Cardiothoracic Surgery, Cincinnati Children's Hospital, Cincinnati, OH; and the 2Pulmonary Medicine, Cincinnati Children's Hospital, Cincinnati, OH. Purpose: Predictors of waitlist (WL) mortality for heart-lung transplant (HLT) has not previously been analyzed. We hypothesized that etiology of failure would be a predictor of mortality prior to receiving a HLT. Methods: Pediatric (<18yo) HLT candidates were identified within the UNOS database (1987-2018). Univariate logistical regression identified risk factors for six-month WL mortality to be included in multivariate analysis. Results: There were 604 HLT candidates identified, 34% (n=206) of whom were transplanted. Only 26% of patients received a transplant by 1 year on the WL with 30% dying. Median time to transplant was 131 days. Diagnoses were Primary Pulmonary Hypertension (IPAH) (n=142), Congenital Heart Disease (CHD) without Eisenmenger Syndrome (ES) (n=67), CHD with ES (n=74), and Other(n=321). Waitlist survival by diagnosis is displayed by Figure 1. There was no significant difference in wait time among the groups (p>0.05) and time on waitlist did not impact post-transplant survival for any diagnosis. On multivariate analysis (Table 1), risk factors for mortality at 6-months included a diagnosis other than CHD with ES (OR: 6.35, 95% CI: 1.9-21.2, p=0.003), IV inotropes (OR: 2.86, 95% CI: 1.585.18, p=0.001), and being an infant (OR: 2.44, 95% CI: 1.42-4.18, p=0.001). Conclusion: Diagnosis is the most important predictor of WL mortality in heart-lung transplantation. Despite similar waiting times to other diagnoses, patients with CHD with ES are the most likely to survive to HLT.
Risk factors for six-month pediatric heart-lung transplant waitlist mortality. Identified Risk Factors Odds Ratio (95% CI) p-value Diagnosis other than CHD with ES* IV Inotropes* Patient Age: Infant* 2-11 years old 12-17 years old Ventilator life support Diagnosis other than CHD without ES Non-Caucasian ECMO support
6.35* (1.9-21.19) 2.86* (1.58-5.18)
0.003* 0.001*
2.44* (1.42-4.18) 1.0 (0.62-1.63) Reference 1.89 (0.97-3.69) 1.44 (0.66-3.16) 1.44 (0.92-2.26) 1.37 (0.56-3.39)
0.001* 0.98 − 0.06 0.36 0.11 0.49
125 Is the Current Era Better for Pediatric Heart-Lung Transplantation? K.W. Riggs,1 J.L. Chapman,1 M. Schecter,2 C. Towe,2 R. Bryant,1 F. Zafar,1 and D.L. Morales.1 1Cardiothoracic Surgery, Cincinnati Children's Hospital, Cincinnati, OH; and the 2Pulmonary Medicine, Cincinnati Children's Hospital, Cincinnati, OH. Purpose: Pediatric heart-lung transplant (HLT) is known to have poor survival. We sought to define if there has been any improvement in pediatric HLT outcomes over time and if there is a cohort that portends better or worse survival. Methods: Pediatric (<18yo) HLT cases were identified within the UNOS database. The data was further divided into Era 1 (1987-1999) and Era 2 (2000-2018). Cox proportional hazard model was used to identify risk factors for post-transplant survival. Results: There has been a 30% drop in pediatric HLT in Era 2. ECMO at transplant has increased from 4% in Era 1 to 12% in Era 2. Similarly, PRA>10% (11.6% to 25.9%, p=0.01), and congenital heart disease (CHD) without Eisenmenger Syndrome (ES) (14% to 25.9%, p=0.03) have increased, whereas, CHD with ES has significantly decreased in Era 2 (23.1% to 9.4%, p=0.01). Two-year post-transplant survival has not changed between eras (p=0.99); however, two-year conditional survival has significantly increased (p=0.01) as shown in Figure 1. Patients on ECMO at transplant have a 7.9 times increased risk of mortality post-transplant (CI: 2.2-29.3, p=0.002). Infant (HR: 2.9, CI: 1.5-5.9, p=0.002) and 2-11 year old (HR: 1.7, CI: 1.0-2.7, p=0.037) patients also have an elevated risk of mortality post-transplant compared to adolescents. Only 13% (2/15) of ECMO patients survived beyond two years post-transplant with a median survival of 64 days, but in the current era, a patient not on ECMO has a median survival of nearly 3 years. Conclusion: Although the number of pediatric HLT has decreased significantly, the long-term outcomes continue to improve post-HLT. With a median post-transplant survival of 2 months for a patient on ECMO, we should be prudent about HLT since it adds little survival benefit. However, in a well selected cohort, HLT can add significant survival benefit.