- Email: [email protected]
Health characteristics of heart transplant recipients surviving into their 80s
j o u r n a l o f s u r g i c a l r e s e a r c h a u g u s t 2 0 1 7 ( 2 1 6 ) 9 9 e1 0 2
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Health characteristics of heart transplant recipients surviving into their 80s Deborah R. Tabachnick, MD,a Megan E. Bowen, MD,a Josef Stehlik, MD, MPH,b Abdallah G. Kfoury, MD,c William T. Caine, MD,d Craig H. Selzman, MD,a and Stephen H. McKellar, MD, MSc,a,* On behalf of the Utah Cardiac Transplant Program (UCTP) a
Division of Cardiothoracic Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah c Department of Cardiology, University of Utah School of Medicine, Salt Lake City, Utah d Intermountain Medical Center, Salt Lake City, Utah b
article info
abstract
Article history:
Background: Heart transplantation (HTx) is the preferred treatment for patients with end-
Received 19 December 2016
stage heart failure and has been successful for >30 y. The clinical course of recipients at
Received in revised form
the extreme of age is unknown. We reviewed our experience to determine the overall
3 April 2017
health and prevalence of Tx-related medical problems for recipients in their ninth decade.
Accepted 26 April 2017
Methods: We reviewed the UCTP experience from 1985 to present to identify patients who
Available online 6 May 2017
survived into their 80s and matched (1:1) with other recipients for gender and age at HTx,
Keywords:
Results: Since 1985, 1129 adult HTx have been performed and 14 patients (1.2%) survived to
Heart failure
80 y old. The mean age at HTx was 63 4 y. Of octogenarians, the majority were males
Heart transplantation
with ischemic cardiomyopathy. The average survival after transplant was 19 5 y in the
Octogenarians
octogenarians and 5 5 y in the controls (P < 0.01). Over time, the prevalence of comor-
Elderly
bidities increased. Compared with nonoctogenarians, we observed higher prevalence of
but did not survive to 80 y. The end point was the prevalence of medical problems.
dyslipidemia (P ¼ 0.02), and chronic renal insufficiency (P ¼ 0.02) during follow-up. Cardiac function was normal (ejection fraction > 55%) for all octogenarians at age 80 y. Conclusions: Despite improvements in posttransplant care, survival of HTx patients into the ninth decade is rare (1%). For those surviving into their 80s, cardiac function is preserved but dyslipidemia, renal insufficiency, and skin cancers are common. As the age of Htx patients continues to increase, posttransplant care should be tailored to minimize postHTx complications and further extend survival. ª 2017 Elsevier Inc. All rights reserved.
Introduction Heart transplantation (HTx) is a treatment for patients with end-stage heart failure. Without HTx, these patients were
relegated to medical management with a poor prognosis.1,2 As experience has matured, graft survival, patient survival, and recipient age have increased. Between 80% and 91% of adult HTx recipients in North America survive the first year3 and
* Corresponding author. Division of Cardiothoracic Surgery, Department of Surgery, University of Utah, 3C127 SOM Salt Lake City, UT 84132. Tel.: þ1 (801) 581 5311; fax: þ1 (801) 587 2973. E-mail address: [email protected] (S.H. McKellar). 0022-4804/$ e see front matter ª 2017 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2017.04.021
100
j o u r n a l o f s u r g i c a l r e s e a r c h a u g u s t 2 0 1 7 ( 2 1 6 ) 9 9 e1 0 2
more than 80% survive 3 y.2,3 Sixty percent of HTx are performed in recipients aged > 50 y and 17% are aged 65 y.4 We know very little about HTx recipients at advanced age with knowledge gaps in areas such as Transplant (Tx) and non-Tx-related medical comorbidities. The UCTP (Utah Affiliated Transplant Hospitals [UTAH] Cardiac Transplant Program) began in 1985, and we reviewed our experience examining the types and prevalence of Tx-related and nonTx-related medical comorbidities.
Methods We performed a retrospective chart review of UCTP recipients aged 18 y at HTx from 1985 to present (University of Utah Medical Center, LDS Hospital/Intermountain Medical Center, and VA Salt Lake Medical Center). Institutional review board approval was obtained at all centers. Recipients surviving into their ninth decade were matched in a 1:1 manner with other recipients by gender, age at HTx, and decade of birth who did not survive to age 80 y. The octogenarian cohort was transplanted in 1986-2004, whereas the control group was transplanted in 1987-2008. We collected data about allograft and renal function and medical and surgical diagnoses and treatments. For continuous variables, mean and standard deviation were calculated and reported. For discrete variables, the proportion of patients with the condition was reported and percentages calculated. JMP software (SAS Institute, Carey, NC) was used for statistical analysis. Given the small sample size, and assumed non-Gaussian distribution, Likelihood Ratio test was used for proportions and the nonparametric Wilcoxon/ KruskalleWallis (rank-sum) test was used for survival.
Results UCTP performed its first HTx in 1985 and has done 1129 adult HTx. Fourteen (1.2%) survived to age 80 y or beyond. As seen in Table, most patients were Caucasian males with ischemic cardiomyopathy. Compared with control patients, the octogenarians had fewer comorbidities at transplant. In the octogenarian cohort, two patients each had one of the preoperative comorbidities we evaluated. The other 12 octogenarian patients had no preoperative comorbidities we collected. In the control group, two patients had three preoperative comorbidities, four patients had two comorbidities, two patients had one comorbidity, and six patients had none (Fig). Specifically, more control patients had diabetes mellitus 3/14 (21%) and left ventricular assist device 3/14 (21%) before HTx compared with octogenarians 0% (P ¼ 0.04 for both). Compared with control subjects, survival after transplant in the octogenarian cohort was an average of 19 5 versus 5 5 y with an average age of 83 2 versus 68 7 y (P < 0.01). Median survival was 19.7 y (range 11.6-26.5 y) and 2.9 y (range 0.0618.6 y), respectively. As a point of reference, median freedom from all-cause mortality for the 1129 transplant patients in our program since 1985 is 11 y while freedom from cardiovascular mortality is 17 y.
Table e Patient data. Variables
Octogenarians (n ¼ 14)
Controls (n ¼ 14)
P
Preoperative demographics 63.2 4.5
63.1 4.8
NS
Male
79%
79%
NS
Caucasian
93%
93%
NS
0%
21%
0.04
Ischemic cardiomyopathy
64%
75%
NS
Preop HTN
14%
36%
NS
Preop DM
0%
21%
0.04
Preop hyperlipidemia
7%
21%
NS
Age at transplant (y)
Preop LVAD
Preop CRI
0%
7%
NS
Malignancy
0%
7%
NS
Posttransplant comorbidities Age at death or last f/u (y)
83 2 (80-86)
68 7
<0.01
Average time after Tx (y)
19.6 5
5.0 5.4
<0.01
EF > 50% at 75
100%
21%
<0.01
EF > 50% at 80
100%
0%
<0.01
Hypertension
57%
43%
NS
Dyslipidemia
71%
29%
0.02
Chronic renal insufficiency
71%
29%
0.02
Diabetes mellitus
43%
21%
NS
Malignancy
71%
36%
NS
CRI ¼ chronic renal insufficiency; DM ¼diabetes mellitus; EF ¼ ejection fraction; HTN ¼ hypertension; LVAD ¼ left ventricular assist device; NS ¼ nonsignificant; preop ¼ preoperative.
There was an increase in Tx and non-Tx-related medical comorbidities among the octogenarians. Described in Table, the prevalence of all measured comorbidities during followup increased over time for the octogenarians. Only dyslipidemia and chronic renal insufficiency (10/14, 71% for both) were significantly increased compared with controls (4/14, 29%; P ¼ 0.02 for both). Also seen in Table, all octogenarians had normal cardiac function measured at age 80 y. Of the controls, the three patients who survived to 75 y of age also had ejection fraction> 50. Medical diagnoses were appropriately treated in the octogenarians. Hypertension, dyslipidemia, and hypothyroidism were treated with beta blockers, statins, and thyroid hormone replacement, respectively. In rarer comorbidities (n ¼ 1 each), deep vein thrombosis was treated with warfarin and atrial arrhythmias were treated with oral antiarrhythmics. Dementia was treated with memantine and donepezil. Permanent pacemakers were required for two recipients. One octogenarian developed prostate cancer and received chemotherapy and radiation 22 y after transplant. Meanwhile, cutaneous malignancies (n ¼ 10) were resected by Mohs or complete surgical excision. Diagnoses requiring surgical intervention resulted in appropriate management. Early surgical interventions
tabachnick et al long-term survivors of heart transplantation
101
Figure e Comorbid conditions identified and their prevalence in control and octogenarian patients during posttransplant followup. Cardiovascular in red, transplant related in blue, and other in green. BPH [ benign prostatic hypertrophy; CAV [ cardiac allograft vasculopathy; Skin Ca [ skin cancer; UTIs [ urinary tract infections. (Color version of the figure is available online.)
included one patient with a necrotic groin wound. He underwent multiple surgical debridement and skin grafting. Another patient had perforated diverticulitis during his transplant admission. He underwent laparotomy, colon resection, and colostomy placement followed by colostomy takedown. Surgical interventions remote to HTx included one corneal transplant 15 y after HTx. Another recipient developed peripheral vascular disease and has had bilateral iliac artery stenting, below knee amputation and femoral to distal bypass. He was placed on hemodialysis for end-stage renal disease that developed 19 y after transplant. Gallstone pancreatitis was treated with a laparoscopic converted to open cholecystectomy 17 y after HTx. Maxillary basal cell carcinoma was treated with resection and radiation. Another octogenarian had a cholecystectomy 1 y after transplant and cataract surgery 24 y after transplant. Twelve octogenarians are still alive. One died at age 90 y from heart failure. The other died of sepsis after a fall at age 84 y. In the control group, only three patients were alive at last follow-up, with the oldest being 78 y old. Causes of death included heart failure, sudden death, sepsis, brain tumor, accelerated humoral rejection, nonesmall cell lung cancer, aspiration pneumonia, and renal failure. Other causes included intracranial hemorrhage secondary to syncope and fall, bradycardic arrest secondary to pneumonia, and sepsis secondary to renal failure.
For the recipients in the control group who did not reach age 80 y, their cause of death is consistent with prior literature as many died of Tx or immunosuppression-related causes.4 The balance between suppressing rejection while allowing adequate immune function in the octogenarian cohort appears to be better achieved than in controls and this topic should be further studied. Although defining medical problems of HTx recipients who survive into their 80s was the primary focus of this study, we did include a control cohort of matched patients who did not survive into their 80s to provide context despite much poorer outcomes in that group. That said, at the time of transplant, the octogenarian cohort was healthier than controls. The octogenarian recipients were transplanted during the years 1986-2004, whereas the control subjects from 1987 to 2008. Our data base was not sufficiently robust to control for gender, age at transplant, and year of transplant, so this may be a confounder. Although this may have led to an imperfect comparison, it should spark discussion of patient and graft survival in older, more complex recipients, as literature has shown these patients have worse survival.5 Other limitations include the retrospective nature of this study and small sample size. The limitations inherent in retrospective studies involving small numbers of patients should eventually be overcome over time as recipient age has continued to increase3 and graft survival has improved allowing more patients for study.
Discussion The principal findings of this study are that HTx recipient survival beyond age 80 y is rare. Recipients who do survive have a high burden of medical and surgical comorbidities that are both Tx and non-Tx-related as a result of age and chronic immunosuppression.
Conclusion HTx recipients can survive into their 80s and beyond, but it is rare. Those who reach 80 y carry a heavy burden of comorbidities which requires careful management. Despite
102
j o u r n a l o f s u r g i c a l r e s e a r c h a u g u s t 2 0 1 7 ( 2 1 6 ) 9 9 e1 0 2
being older and sicker patients, they continue to receive treatment for their conditions. Future studies will need to evaluate HTx patients’ medical problems over time to improve outcomes in this unique cohort of transplant recipients.
Acknowledgment The authors would like to acknowledge Dale G. Renlund, MD, for his leadership of the UTAH Cardiac Transplant Program for many years of its existence. There are no relevant funding or author disclosures for this article. Authors’ contributions: D.R.T., J.S., A.G.K., M.E.B., and S.H.M. contributed to study design. All authors participated in data collection and article preparation.
Disclosure The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in the article.
references
1. Rose EA, Gelijns AC, Moskowitz AJ, et al. Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) study group. Long-term use of a left ventricular assist device for end-stage heart failure. N Engl J Med. 2001;345:1435e1443. 2. Weiss ES, Nwakanma LU, Patel ND, Yuh DD. Outcomes in patients older than 60 years of age undergoing orthotopic heart transplantation: an analysis of the UNOS database. J Heart Lung Transplant. 2008;27:184e191. 3. ISHLT.org. ISHLT transplant registry quarterly reports for heart in North America. Addison, TX: The International Society for Heart and Lung Transplantation; 2016. Available at: http://www.ishlt. org/registries/quarterlyDataReportResults.asp?organ¼HR& rptType¼all&continent¼4. Accessed December 16, 2016. 4. Birati EY, Mathelier H, Molina M, et al. Comparison of causes of death after heart transplantation in patients with left ventricular ejection fractions 35% versus >35. Am J Cardiol. 2016;117:1322e1326. 5. Allen JG, Kilic A, Weiss ES, et al. Should patients 60 years and older undergo bridge to transplantation with continuous-flow left ventricular assist devices? Ann Thorac Surg. 2012;94:2017e2024.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Health characteristics of heart transplant recipients surviving into their 80s Deborah R. Tabachnick, MD,a Megan E. Bowen, MD,a Josef Stehlik, MD, MPH,b Abdallah G. Kfoury, MD,c William T. Caine, MD,d Craig H. Selzman, MD,a and Stephen H. McKellar, MD, MSc,a,* On behalf of the Utah Cardiac Transplant Program (UCTP) a
Division of Cardiothoracic Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah c Department of Cardiology, University of Utah School of Medicine, Salt Lake City, Utah d Intermountain Medical Center, Salt Lake City, Utah b
article info
abstract
Article history:
Background: Heart transplantation (HTx) is the preferred treatment for patients with end-
Received 19 December 2016
stage heart failure and has been successful for >30 y. The clinical course of recipients at
Received in revised form
the extreme of age is unknown. We reviewed our experience to determine the overall
3 April 2017
health and prevalence of Tx-related medical problems for recipients in their ninth decade.
Accepted 26 April 2017
Methods: We reviewed the UCTP experience from 1985 to present to identify patients who
Available online 6 May 2017
survived into their 80s and matched (1:1) with other recipients for gender and age at HTx,
Keywords:
Results: Since 1985, 1129 adult HTx have been performed and 14 patients (1.2%) survived to
Heart failure
80 y old. The mean age at HTx was 63 4 y. Of octogenarians, the majority were males
Heart transplantation
with ischemic cardiomyopathy. The average survival after transplant was 19 5 y in the
Octogenarians
octogenarians and 5 5 y in the controls (P < 0.01). Over time, the prevalence of comor-
Elderly
bidities increased. Compared with nonoctogenarians, we observed higher prevalence of
but did not survive to 80 y. The end point was the prevalence of medical problems.
dyslipidemia (P ¼ 0.02), and chronic renal insufficiency (P ¼ 0.02) during follow-up. Cardiac function was normal (ejection fraction > 55%) for all octogenarians at age 80 y. Conclusions: Despite improvements in posttransplant care, survival of HTx patients into the ninth decade is rare (1%). For those surviving into their 80s, cardiac function is preserved but dyslipidemia, renal insufficiency, and skin cancers are common. As the age of Htx patients continues to increase, posttransplant care should be tailored to minimize postHTx complications and further extend survival. ª 2017 Elsevier Inc. All rights reserved.
Introduction Heart transplantation (HTx) is a treatment for patients with end-stage heart failure. Without HTx, these patients were
relegated to medical management with a poor prognosis.1,2 As experience has matured, graft survival, patient survival, and recipient age have increased. Between 80% and 91% of adult HTx recipients in North America survive the first year3 and
* Corresponding author. Division of Cardiothoracic Surgery, Department of Surgery, University of Utah, 3C127 SOM Salt Lake City, UT 84132. Tel.: þ1 (801) 581 5311; fax: þ1 (801) 587 2973. E-mail address: [email protected] (S.H. McKellar). 0022-4804/$ e see front matter ª 2017 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2017.04.021
100
j o u r n a l o f s u r g i c a l r e s e a r c h a u g u s t 2 0 1 7 ( 2 1 6 ) 9 9 e1 0 2
more than 80% survive 3 y.2,3 Sixty percent of HTx are performed in recipients aged > 50 y and 17% are aged 65 y.4 We know very little about HTx recipients at advanced age with knowledge gaps in areas such as Transplant (Tx) and non-Tx-related medical comorbidities. The UCTP (Utah Affiliated Transplant Hospitals [UTAH] Cardiac Transplant Program) began in 1985, and we reviewed our experience examining the types and prevalence of Tx-related and nonTx-related medical comorbidities.
Methods We performed a retrospective chart review of UCTP recipients aged 18 y at HTx from 1985 to present (University of Utah Medical Center, LDS Hospital/Intermountain Medical Center, and VA Salt Lake Medical Center). Institutional review board approval was obtained at all centers. Recipients surviving into their ninth decade were matched in a 1:1 manner with other recipients by gender, age at HTx, and decade of birth who did not survive to age 80 y. The octogenarian cohort was transplanted in 1986-2004, whereas the control group was transplanted in 1987-2008. We collected data about allograft and renal function and medical and surgical diagnoses and treatments. For continuous variables, mean and standard deviation were calculated and reported. For discrete variables, the proportion of patients with the condition was reported and percentages calculated. JMP software (SAS Institute, Carey, NC) was used for statistical analysis. Given the small sample size, and assumed non-Gaussian distribution, Likelihood Ratio test was used for proportions and the nonparametric Wilcoxon/ KruskalleWallis (rank-sum) test was used for survival.
Results UCTP performed its first HTx in 1985 and has done 1129 adult HTx. Fourteen (1.2%) survived to age 80 y or beyond. As seen in Table, most patients were Caucasian males with ischemic cardiomyopathy. Compared with control patients, the octogenarians had fewer comorbidities at transplant. In the octogenarian cohort, two patients each had one of the preoperative comorbidities we evaluated. The other 12 octogenarian patients had no preoperative comorbidities we collected. In the control group, two patients had three preoperative comorbidities, four patients had two comorbidities, two patients had one comorbidity, and six patients had none (Fig). Specifically, more control patients had diabetes mellitus 3/14 (21%) and left ventricular assist device 3/14 (21%) before HTx compared with octogenarians 0% (P ¼ 0.04 for both). Compared with control subjects, survival after transplant in the octogenarian cohort was an average of 19 5 versus 5 5 y with an average age of 83 2 versus 68 7 y (P < 0.01). Median survival was 19.7 y (range 11.6-26.5 y) and 2.9 y (range 0.0618.6 y), respectively. As a point of reference, median freedom from all-cause mortality for the 1129 transplant patients in our program since 1985 is 11 y while freedom from cardiovascular mortality is 17 y.
Table e Patient data. Variables
Octogenarians (n ¼ 14)
Controls (n ¼ 14)
P
Preoperative demographics 63.2 4.5
63.1 4.8
NS
Male
79%
79%
NS
Caucasian
93%
93%
NS
0%
21%
0.04
Ischemic cardiomyopathy
64%
75%
NS
Preop HTN
14%
36%
NS
Preop DM
0%
21%
0.04
Preop hyperlipidemia
7%
21%
NS
Age at transplant (y)
Preop LVAD
Preop CRI
0%
7%
NS
Malignancy
0%
7%
NS
Posttransplant comorbidities Age at death or last f/u (y)
83 2 (80-86)
68 7
<0.01
Average time after Tx (y)
19.6 5
5.0 5.4
<0.01
EF > 50% at 75
100%
21%
<0.01
EF > 50% at 80
100%
0%
<0.01
Hypertension
57%
43%
NS
Dyslipidemia
71%
29%
0.02
Chronic renal insufficiency
71%
29%
0.02
Diabetes mellitus
43%
21%
NS
Malignancy
71%
36%
NS
CRI ¼ chronic renal insufficiency; DM ¼diabetes mellitus; EF ¼ ejection fraction; HTN ¼ hypertension; LVAD ¼ left ventricular assist device; NS ¼ nonsignificant; preop ¼ preoperative.
There was an increase in Tx and non-Tx-related medical comorbidities among the octogenarians. Described in Table, the prevalence of all measured comorbidities during followup increased over time for the octogenarians. Only dyslipidemia and chronic renal insufficiency (10/14, 71% for both) were significantly increased compared with controls (4/14, 29%; P ¼ 0.02 for both). Also seen in Table, all octogenarians had normal cardiac function measured at age 80 y. Of the controls, the three patients who survived to 75 y of age also had ejection fraction> 50. Medical diagnoses were appropriately treated in the octogenarians. Hypertension, dyslipidemia, and hypothyroidism were treated with beta blockers, statins, and thyroid hormone replacement, respectively. In rarer comorbidities (n ¼ 1 each), deep vein thrombosis was treated with warfarin and atrial arrhythmias were treated with oral antiarrhythmics. Dementia was treated with memantine and donepezil. Permanent pacemakers were required for two recipients. One octogenarian developed prostate cancer and received chemotherapy and radiation 22 y after transplant. Meanwhile, cutaneous malignancies (n ¼ 10) were resected by Mohs or complete surgical excision. Diagnoses requiring surgical intervention resulted in appropriate management. Early surgical interventions
tabachnick et al long-term survivors of heart transplantation
101
Figure e Comorbid conditions identified and their prevalence in control and octogenarian patients during posttransplant followup. Cardiovascular in red, transplant related in blue, and other in green. BPH [ benign prostatic hypertrophy; CAV [ cardiac allograft vasculopathy; Skin Ca [ skin cancer; UTIs [ urinary tract infections. (Color version of the figure is available online.)
included one patient with a necrotic groin wound. He underwent multiple surgical debridement and skin grafting. Another patient had perforated diverticulitis during his transplant admission. He underwent laparotomy, colon resection, and colostomy placement followed by colostomy takedown. Surgical interventions remote to HTx included one corneal transplant 15 y after HTx. Another recipient developed peripheral vascular disease and has had bilateral iliac artery stenting, below knee amputation and femoral to distal bypass. He was placed on hemodialysis for end-stage renal disease that developed 19 y after transplant. Gallstone pancreatitis was treated with a laparoscopic converted to open cholecystectomy 17 y after HTx. Maxillary basal cell carcinoma was treated with resection and radiation. Another octogenarian had a cholecystectomy 1 y after transplant and cataract surgery 24 y after transplant. Twelve octogenarians are still alive. One died at age 90 y from heart failure. The other died of sepsis after a fall at age 84 y. In the control group, only three patients were alive at last follow-up, with the oldest being 78 y old. Causes of death included heart failure, sudden death, sepsis, brain tumor, accelerated humoral rejection, nonesmall cell lung cancer, aspiration pneumonia, and renal failure. Other causes included intracranial hemorrhage secondary to syncope and fall, bradycardic arrest secondary to pneumonia, and sepsis secondary to renal failure.
For the recipients in the control group who did not reach age 80 y, their cause of death is consistent with prior literature as many died of Tx or immunosuppression-related causes.4 The balance between suppressing rejection while allowing adequate immune function in the octogenarian cohort appears to be better achieved than in controls and this topic should be further studied. Although defining medical problems of HTx recipients who survive into their 80s was the primary focus of this study, we did include a control cohort of matched patients who did not survive into their 80s to provide context despite much poorer outcomes in that group. That said, at the time of transplant, the octogenarian cohort was healthier than controls. The octogenarian recipients were transplanted during the years 1986-2004, whereas the control subjects from 1987 to 2008. Our data base was not sufficiently robust to control for gender, age at transplant, and year of transplant, so this may be a confounder. Although this may have led to an imperfect comparison, it should spark discussion of patient and graft survival in older, more complex recipients, as literature has shown these patients have worse survival.5 Other limitations include the retrospective nature of this study and small sample size. The limitations inherent in retrospective studies involving small numbers of patients should eventually be overcome over time as recipient age has continued to increase3 and graft survival has improved allowing more patients for study.
Discussion The principal findings of this study are that HTx recipient survival beyond age 80 y is rare. Recipients who do survive have a high burden of medical and surgical comorbidities that are both Tx and non-Tx-related as a result of age and chronic immunosuppression.
Conclusion HTx recipients can survive into their 80s and beyond, but it is rare. Those who reach 80 y carry a heavy burden of comorbidities which requires careful management. Despite
102
j o u r n a l o f s u r g i c a l r e s e a r c h a u g u s t 2 0 1 7 ( 2 1 6 ) 9 9 e1 0 2
being older and sicker patients, they continue to receive treatment for their conditions. Future studies will need to evaluate HTx patients’ medical problems over time to improve outcomes in this unique cohort of transplant recipients.
Acknowledgment The authors would like to acknowledge Dale G. Renlund, MD, for his leadership of the UTAH Cardiac Transplant Program for many years of its existence. There are no relevant funding or author disclosures for this article. Authors’ contributions: D.R.T., J.S., A.G.K., M.E.B., and S.H.M. contributed to study design. All authors participated in data collection and article preparation.
Disclosure The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in the article.
references
1. Rose EA, Gelijns AC, Moskowitz AJ, et al. Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) study group. Long-term use of a left ventricular assist device for end-stage heart failure. N Engl J Med. 2001;345:1435e1443. 2. Weiss ES, Nwakanma LU, Patel ND, Yuh DD. Outcomes in patients older than 60 years of age undergoing orthotopic heart transplantation: an analysis of the UNOS database. J Heart Lung Transplant. 2008;27:184e191. 3. ISHLT.org. ISHLT transplant registry quarterly reports for heart in North America. Addison, TX: The International Society for Heart and Lung Transplantation; 2016. Available at: http://www.ishlt. org/registries/quarterlyDataReportResults.asp?organ¼HR& rptType¼all&continent¼4. Accessed December 16, 2016. 4. Birati EY, Mathelier H, Molina M, et al. Comparison of causes of death after heart transplantation in patients with left ventricular ejection fractions 35% versus >35. Am J Cardiol. 2016;117:1322e1326. 5. Allen JG, Kilic A, Weiss ES, et al. Should patients 60 years and older undergo bridge to transplantation with continuous-flow left ventricular assist devices? Ann Thorac Surg. 2012;94:2017e2024.