Heart Transplantation in Adults With Congenital Heart Disease

Study Questions:

What is the effect of center adult congenital heart disease (CHD) transplant volume and expertise on transplant outcomes in CHD patients?

Methods:

The United Network of Organ Sharing (UNOS) database was used to study heart transplantations in CHD patients ages ≥18 years between January 2000 and June 2019. The primary outcomes were waitlist mortality and post-transplant outcomes at 30 days and 1 year. Transplant centers were assessed as the highest CHD transplant volume center in a UNOS region versus all others, as well as by presence of Adult Congenital Heart Association (ACHA) accreditation and adult versus pediatric hospital designation.

Results:

During the study period, 1,746 adult CHD patients were listed for transplant, of which 1,006 (57.6%) underwent heart transplantation. After adjusting for age, sex, listing status, and inotrope requirement, waitlist mortality was lower at ACHA accredited centers (hazard ratio, 0.730; p = 0.020). Post-transplant 30-day mortality was lower at the highest volume CHD transplant center in each UNOS region (hazard ratio, 0.706; p = 0.014).

Conclusions:

The authors concluded that designated expertise in CHD care is associated with improved waitlist outcomes for CHD patients listed for transplantation. As post-transplant survival was improved at the highest volume regional center, there may be an advantage to regionalization of CHD transplantation.

Perspective:

This study examined outcomes of adult CHD patients undergoing cardiac transplantation. These patients represent a high-risk group for transplant because they have often undergone multiple previous sternotomies, have significant allosensitization, and often have end-organ dysfunction including renal and liver disease. Waitlist mortality was lower at centers with ACHA accreditation. Although the vast majority of the study period occurred prior to the existence of ACHA program accreditation, ACHA accreditation was likely a surrogate for programs with a comprehensive, multidisciplinary adult congenital heart program. Interestingly, while waitlist mortality was lower in patients with previous sternotomy undergoing transplant at pediatric centers, 30-day and 1-year mortality was higher at these centers. While the database did not provide diagnosis-specific data, it is possible that more complex patients were listed at pediatric centers.

Clinical Topics: Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Cardiac Surgery and CHD and Pediatrics, Cardiac Surgery and Heart Failure, Congenital Heart Disease, CHD and Pediatrics and Interventions, CHD and Pediatrics and Quality Improvement, Acute Heart Failure, Heart Transplant, Interventions and Structural Heart Disease

Keywords: Accreditation, Graft Survival, Heart Defects, Congenital, Heart Failure, Heart Transplantation, Hospitals, Pediatric, Liver Diseases, Outcome Assessment (Health Care), Renal Insufficiency, Sternotomy


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