Heart retransplantation: The 25-year experience at a single institution

Background: The current critical shortage of cardiac allograft donors means that the decision to offer a patient repeat heart transplantation must be carefully considered. Since 1968, a total of 66 heart retransplantation procedures (63 first-time and three second-time) have been performed in 63 patients at Stanford. Methods: There were 52 male and 11 female patients, ranging in age from 3 to 62 years with a mean age of 41 years. Indications for retransplantation were primary allograft failure in nine patients, acute allograft rejection in 17, graft atherosclerosis in 37, and constrictive disease in three. Six of the seventeen patients (35%) who underwent retransplantation before 1981 died in the hospital, and none are currently alive. Of the 46 patients who underwent retransplantation since 1981 treated with cyclosporine-based immunosuppression, 11 (24%) died in the hospital. Actuarial survival estimates for the whole retransplantation group at 1, 5, and 10 years were 55% ± 8%, 33% ±8%, and 22% ± 7%, respectively. Results: This survival was significantly worse (p < 0.05) than that in patients undergoing primary heart transplantation (81% ± 2%, 62% ± 2%, 44% ± 13% at 1, 5, and 10 years). Those patients who underwent retransplantation for graft atherosclerosis since 1981 had a significantly better 1-year survival (p < 0.05) than those who underwent retransplantation for allograft rejection (69% ± 10% versus 33% ± 16%), but the 5-year survival was similar in both groups (34% ± 11% versus 33% ± 16%). Since 1981, actuarial freedoms from infection and rejection were 22% ± 8% and 41% ± 9%, respectively, at 1 year, and 7% ± 7% and 36% ± 9% at 5 years. Patients with cyclosporine-induced renal dysfunction (serum creatinine level of greater than 2.0 mg/dl) had a high probability of requiring postoperative dialysis and also of death after retransplantation. Three patients with significant cyclosporine-induced renal dysfunction underwent simultaneous kidney transplantation and heart retransplantation, and all were alive and well at the time this article was written. Sixteen patients were also currently alive at a mean follow-up of 44 months, and 15 were in New York Heart Association functional class I. Conclusions: We continue to list carefully selected candidates with good rehabilitation potential for heart retransplantation.