A retrospective analysis of 7 patients who died after heart transplantation in a single center, and to explore the risk factors for death after heart transplantation.

From May 1, 2015 to May 1, 2019, 74 cases of orthotopic heart transplantation were performed in the Department of Cardiovascular Surgery, Renmin Hospital of Wuhan University. By April 2020, with a follow-up time of 724 days, 65 recipients survived and 9 died. Two cases of death due to non-medical causes were excluded, and the recipients were divided into survival group (65 cases) and death group (7 cases). Preoperative, intraoperative, and postoperative parameters and corresponding donor conditions were collected for the survival group. Continuous variables that met the normal distribution were compared using the t-test, and continuous variables that were not normally distributed were analyzed using the Kruskal-Wallis test. Enumeration data were compared using Fisher′s exact test. Survival curves were plotted using the Kaplan-Meier method. Cox proportional hazards models were used to analyze risk factors for death after heart transplantation.

Of the 7 dead recipients, 4 died of transplant heart failure, rejection, respiratory failure and other organ failure during hospitalization, including 1 recipient of combined heart-lung transplantation and 3 recipients who died during follow-up: 2 cases with poor compliance with immunosuppressive agents, 1 case with transplant heart failure, rejection and liver failure. There were no significant differences in age at operation, body mass index, left ventricular ejection fraction, primary disease, preoperative cardiopulmonary resuscitation, vasoactive drug maintenance and ECMO transition between the surviving recipients (P>0.05). There were no significant differences in donor age, poor body weight, donor cold ischemia time, cause of brain death, donor/recipient sex and ABO blood group matching, and marginal donor ratio in the death and survival groups (P>0.05), and the proportion of donor/recipient age difference (>17 years) in the death group was higher than that in the survival group (P<0.05). The median cardiopulmonary bypass time was 201 (185, 226) and 170 (152, 197) min, the intraoperative packed red blood cell dosage was 8.0 (5.5, 9.0) and 4.0 (2.0, 6.0) U, and the platelet dosage was 4.0 (2.0, 6.0) and 2.0 (2.0, 2.0) U in the surviving recipients, and the differences were statistically significant (P<0.05). The ICU stay and postoperative ventilator use time of recipients in the death group were longer than those in the survival group, 11.1 (5.9, 17.7) and 3.8 (2.9-5.0) d, 58 (12, 172) and 8 (6, 15) h, respectively; meanwhile, the proportion of recipients who stayed in the ICU (stay >5 d) and used the ventilator for a long time (use > 24 h) in the death group was higher than that in the survival group, and the differences were statistically significant (P<0.05 for all). The 1-, 3-, and 5-year overall survival rates of the 74 recipients were 91.9%, 84.7%, and 74.1%, respectively. The factors with statistically significant differences in preoperative and intraoperative indicators and corresponding donor indicators between the two groups were included in Cox proportional hazards model analysis. The results showed that intraoperative platelet dosage was an independent risk factor for death after heart transplantation. For every U increase in intraoperative platelet use, the risk of postoperative death increased by 1.35 times (HR=2.35, 95% CI 1.28~4.32, P<0.05).

The outcome after heart transplantation is influenced by many factors. Excessive differences in intraoperative red blood cell and platelet dosage and donor/recipient age are risk factors for death after heart transplantation.