2002ISHLT
HEART TRANSPLANTATION
Overall
2002ISHLT
NUMBER OF HEART TRANSPLANTS REPORTED BY YEAR
* Numbers may be low due to delayed reporting.
0
500
1000
1500
2000
2500
3000
3500
4000
45001
98
2
19
83
19
84
19
85
19
86
19
87
19
88
19
89
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
*
Nu
mb
er o
f T
ran
spla
nts
*
2002ISHLT
HEART TRANSPLANTS: Donor Age by Year of Transplant
0
1500
3000
450019
82
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
Nu
mb
er
of
Tra
ns
pla
nts
0-10 11-17 18-35 36-49 50-59 60+
2002ISHLT
AGE DISTRIBUTIONOF HEART RECIPIENTS (1982-2001)
% o
f T
r%
of
Tra
ns
pla
nts
ns
pla
nts
0
10
20
30
40
50
60
<1 1-5 6-10 11-17 18-34 35-49 50-64 65+
Recipient Age
2002ISHLT
AGE DISTRIBUTION OF HEART TRANSPLANT RECIPIENTS BY ERA
0
10
20
30
40
50
60
<11-
56-
10
11-1
7
18-3
4
35-4
9
50-6
465
+ <11-
56-
10
11-1
7
18-3
4
35-4
9
50-6
465
+
% o
f tr
an
sp
lan
ts
1985-1996 1997-2001
2002ISHLT
HEART TRANSPLANTATION Actuarial Survival (1982-2001)
0
20
40
60
80
100
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Years Post-Transplantation
Sur
viva
l (%
)
N=60,936
Half-life = 9.3 yearsConditional Half-life = 11.8 years
2002ISHLT
HEART TRANSPLANTATION
Adult Recipients
2002ISHLT
Congenital2%
ReTX2%
Myopathy45%
Misc.2%
Valvular4%
CAD45%
DIAGNOSIS IN ADULT HEART TRANSPLANTS
20
3040
5060
70
1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
% o
f Cas
es
Myopathy CAD
2002ISHLT
ADULT HEART TRANSPLANTATION Actuarial Survival by Era (1982-2001)
0
20
40
60
80
100
0 1 2 3 4 5 6 7 8
Years Post-Transplantation
1982-1987 (N=6,337)
1988-1992 (N=16,596)
1993-1997 (N=18,740)
1998-2001 (N=12,083)
All comparisons significant at p < 0.002
Su
rviv
al (
%)
2002ISHLT
ADULT HEART TRANSPLANTATION Actuarial Survival by Age Group (1982-2001)
0
20
40
60
80
100
0 1 2 3 4 5 6 7 8
Years Post-Transplantation
18-34 (N=5,608) 35-49 (N=15,866)50-64 (N=29,387) 65-69 (N=2,407)70+ (N = 239)
Su
rviv
al (
%)
Survival comparisonsAll pair-wise comparisons are statistically significant at p < 0.05 except:18-34 vs. 35-49 and 65-69 vs. 70+
2002ISHLT
0
20
40
60
80
0-2 months >2-6 months >6-12months
>12-36months
>36-60months
>60 months
Time between previous and current transplant
1 Y
ear
Pat
ien
t S
urv
ival
(%
) 1982-1990
1991-2000
ADULT HEART RE-TRANSPLANTS1-Year Survival
124
170
32
32
29
31
64
95
3588
22 271
2002ISHLT
ADULT HEART TRANSPLANTS (1996-2001) Risk Factors for 1 Year Mortality
In Descending Order of Magnitude
N=13,049
VARIABLE Odds Ratio P-value
95% Confidence
Interval
ECMO 3.00 0.009 1.32 -6.85
Ventilator 2.94 <.0001 2.23 -3.86
Diagnosis: Congenital Heart Disease 2.34 <.0001 1.66 -3.31
IABP 1.53 0.0005 1.21 -1.94
Previous Transplant 1.50 0.01 1.10 -2.06
VAD 1.45 <.0001 1.25 -1.69
2002ISHLT
ADULT HEART TRANSPLANTS (1996-2001) Risk Factors for 1 Year Mortality
In Descending Order of Magnitude
N=13,049
VARIABLE Odds Ratio P-value
95% Confidence
Interval Diagnosis: Other than Congenital, Myopathy or Coronary Artery Disease
1.36 0.002 1.12 -1.66
Donor History of Hypertension
1.24 0.01 1.05 -1.47
Male Recipient/Female Donor
1.18 0.005 1.05 -1.33
Diagnosis: Coronary Artery Disease
1.16 0.007 1.04 -1.30
2002ISHLT
ADULT HEART TRANSPLANTS (1996-2001) Risk Factors for 1 Year Mortality
Continuous Factors
N=13,049
VARIABLE Odds Ratio p-value Recipient Age – linear < 0.0001
20 years 0.74
35 years 0.85
50 years 0.99
65 years 1.15
Donor Age - linear < 0.0001
20 years 0.84
35 years 1.07
50 years 1.38
65 years 1.77
2002ISHLT
ADULT HEART TRANSPLANTS (1996-2001) Risk Factors for 1 Year Mortality
Continuous Factors
N=13,049
VARIABLE Odds Ratio p-value Recipient Height – linear < 0.0001
140 cm 1.66
160 cm 1.23
180 cm 0.91
200 cm 0.67
2002ISHLT
ADULT HEART TRANSPLANTS (1996-2001) Risk Factors for 1 Year Mortality
Continuous Factors
N=13,049
VARIABLE Odds Ratio p-value Ischemia Time – linear < 0.0001
Ischemia Time - quadratic 0.009
1 hour 0.69
3 hours 1.04
5 hours 1.45
7 hours 1.90
Center Volume - linear < 0.0001
5 transplants/year 1.21
10 transplants/year 1.17
50 transplants/year 0.89
100 transplants/year 0.64
2002ISHLT
ADULT HEART TRANSPLANTS (1996-2001) Risk Factors for 1 Year Mortality
Continuous Factors
N=13,049
VARIABLE Odds Ratio p-value Most Recent PRA – linear < 0.0001
0% 0.96 25% 1.26 50% 1.65 75% 2.16
100% 2.83 Bilirubin (mg/dl) – linear < 0.0001
1 0.97 5 1.11
10 1.31 25 2.14
2002ISHLT
ADULT HEART TRANSPLANTS (1996-2001) Factors Not Significant for 1 Year Mortality
•Year of Transplant•In ICU or hospital prior to transplant•On inotropes for life support•ICD•CMV mismatch•Recipient pregnancy status•Weight (donor or recipient)•Height (donor)•Donor clinical infection•Donor cause of death
2002ISHLT
ADULT HEART TRANSPLANTS (April 1994-December 1996) Risk Factors for 5 Year Mortality
In Descending Order of Magnitude
N=9,519
VARIABLE Odds Ratio P-value
95% Confidence
Interval
Previous Transplant 2.09 <.0001 1.56 -2.79
Donor COD: Other (not head trauma, CVA, CNS tumor, or anoxia)
1.59 <.0001 1.39 -1.80
Ventilator 1.53 0.008 1.12 -2.10
Diagnosis: Coronary Artery Disease 1.23 <.0001 1.12 -1.35
Male Recipient/ Female Donor 1.15 0.01 1.03 -1.29
Implantable Defibrillator 0.70 0.0007 0.56 -0.86
2002ISHLT
ADULT HEART TRANSPLANTS (April 1994-December 1996) Risk Factors for 5 Year Mortality
Continuous Factors
N=9,519
VARIABLE Odds Ratio p-value Recipient Age – quadratic 0.001
20 years 1.49
35 years 1.11
50 years 1.00
65 years 1.09
Donor Age - linear < 0.0001
20 years 0.82
35 years 1.08
50 years 1.44
65 years 1.90
2002ISHLT
ADULT HEART TRANSPLANTS (April 1994-December 1996) Risk Factors for 5 Year Mortality
Continuous Factors
N=9,519
VARIABLE Odds Ratio p-value Ischemia Time – linear 0.006
1 hour 0.88
3 hours 1.01
5 hours 1.16
7 hours 1.33
Center Volume - linear 0.0001
Center Volume – quadratic 0.0008
5 transplants/year 1.31
10 transplants/year 1.23
50 transplants/year 0.95
100 transplants/year 1.27
2002ISHLT
ADULT HEART TRANSPLANTS (April 1994-December 1996) Risk Factors for 5 Year Mortality
Continuous Factors
N=9,519
VARIABLE Odds Ratio p-value Recipient Height – linear < 0.0001
140 cm 1.49
160 cm 1.17
180 cm 0.93
200 cm 0.73
Recipient Bilirubin (mg/dl) - linear 0.02
1 0.98
5 1.09
10 1.26
25 1.91
2002ISHLT
ADULT HEART TRANSPLANTS (April 1994-December 1996) Factors Not Significant for 5 Year Mortality
•Year of Transplant•VAD/ECMO/IABP•In ICU or hospital prior to transplant•On inotropes for life support•CMV mismatch•Recipient pregnancy status•Weight (donor or recipient)•Height (donor)•Donor clinical infection•Donor history of hypertension
2002ISHLT
ADULT HEART TRANSPLANTS (April 1994-December 1996) Risk Factors for 5 Year Mortality Conditional on Survival to 1 Year
In Descending Order of Magnitude
N=7,738
VARIABLE Odds Ratio P-value
95% Confidence
Interval
CAV within 1st Year 1.88 <.0001 1.46 -2.43
Previous Transplant 1.84 0.002 1.26 -2.71
Rejection within 1st Year 1.40 <.0001 1.22 -1.60
Diagnosis: Coronary Artery Disease
1.28 0.0002 1.13 -1.46
Implantable Defibrillator 0.68 0.008 0.52 -0.90
2002ISHLT
ADULT HEART TRANSPLANTS (April 1994-December 1996) Risk Factors for 5 Year Mortality Conditional on Survival to 1 Year
Continuous Factors
N=7,738
VARIABLE Odds Ratio p-value Recipient Age – quadratic 0.0002
20 years 1.81
35 years 1.17
50 years 1.00
65 years 1.14
2002ISHLT
ADULT HEART TRANSPLANTS (April 1994-December 1996) Risk Factors for 5 Year Mortality Conditional on Survival to 1 Year
Continuous Factors
N=7,738
VARIABLE Odds Ratio p-value Donor Age - linear < 0.0001
Center Volume – linear 0.0001
Interaction of Donor Age (quadratic) and Center Volume (quadratic)
(see graph)
0.03
2002ISHLT
ADULT HEART TRANSPLANTS (April 1994-December 1996) Risk Factors for 5 Year Mortality Conditional on Survival to 1 Year:
Combination of Donor Age and Center Volume
0
0.5
1
1.5
2
20 35 50 65Donor Age
Od
ds
Rat
io f
or
5 Y
ear
Mo
rtal
ity
Center Volume = 5 transplants/yearCenter Volume = 10 transplants/yearCenter Volume = 50 transplants/yearCenter Volume = 100 transplants/year
2002ISHLT
ADULT HEART TRANSPLANTS (April 1994-December 1996) Factors Not Significant for Conditional 5 Year Mortality
•Year of Transplant•Any form of life support•CMV mismatch•Ischemia time•Bilirubin•Donor cause of death
•In ICU or hospital prior to tx •Weight (donor or recipient)•Height (donor or recipient)•Gender (donor or recipient)•Donor clinical infection•Recipient pregnancy status
2002ISHLT
ADULT HEART RECIPIENTS Functional Status (April 1994-December 2001)
0%
20%
40%
60%
80%
100%
1 Year (N=11,908) 3 Years (N=10,446) 5 Years (N=8,873)
No Activity Limitations Performs with Some Assistance Requires Total Assistance
2002ISHLT
ADULT HEART RECIPIENTS Employment Status (U.S. Data: April 1994-December 2001)
0%
20%
40%
60%
80%
100%
1 Year (N=11,126)
3 Years (N=9,606)
5 Years (N=8,083)
Retired
Not Working
Working Part Time
Working Full Time
2002ISHLT
ADULT HEART RECIPIENTSRehospitalization Post-transplant (April 1994 - December 2001)
0%
20%
40%
60%
80%
100%
Up to 1 Year (N=12,889)
Between 2 and 3Years (N=10,993)
Between 4 and 5Years (N=9,336)
No Hospitalization Hospitalized: Not Rejection/Not Infection
Hospitalized: Rejection Only Hospitalized: Infection Only
Hospitalized: Rejection + Infection
2002ISHLT
0
10
20
30
40
50
Any Induction (N = 2,257)
Polyclonal ATG/ALG (N =1,196)
OKT3 (N = 695) IL2-R Antagonist (N =766)
% o
f p
ati
en
tsADULT HEART RECIPIENTS
Induction Immunosuppression For follow-ups between October 1999 and December 2001
2002ISHLT
0
20
40
60
80
100
Cyclosporine Tacrolimus Rapamycin MMF Azathioprine Prednisone
% o
f P
ati
en
ts
Year 1 (N = 4,072)
Year 5 (N = 2,928)
ADULT HEART RECIPIENTS Maintenance Immunosuppression at Any Time During Follow-up Period
For follow-ups between October 1999 and December 2001
2002ISHLT
0
20
40
60
80
100
Cyclosporine Tacrolimus Rapamycin MMF Azathioprine Prednisone
% o
f P
ati
en
ts
Year 1 (N = 3,165) Year 5 (N =2,588)
ADULT HEART RECIPIENTS Maintenance Immunosuppression at Time of Follow-up
For follow-ups between October 1999 and December 2001
2002ISHLT
0
20
40
60
80
100
CalcineurinInhibitor
CellCycle Prednisone CalcineurinInhibitor
CellCycle Prednisone
% o
f P
ati
en
ts
CyA
TacTac
CyA
AZA
AZA
MMF
MMF
ADULT HEART RECIPIENTS Maintenance Immunosuppression at Time of Follow-up
For follow-ups between October 1999 and December 2001
1 Year Follow-up (N = 3,165) 5 Year Follow-up (N = 2,588)
2002ISHLT
0%
20%
40%
60%
80%
100%
Year 1 (N = 3,165) Year 5 (N = 2,588)
% o
f P
ati
en
ts
None Given
Other
Tacrolimus + MMF
Tacrolimus + AZA
Cyclosporine + MMF
Cyclosporine + AZA
ADULT HEART RECIPIENTS Maintenance Immunosuppression at Time of Follow-up
For follow-ups between October 1999 and December 2001
2002ISHLT
POST-HEART TRANSPLANT MORBIDITY FOR ADULTS Cumulative Incidence for Survivors (April 1994-December 2000)
Outcome By 1 Year By 5 Years
Hypertension 72.4% (N=12,496)
95.1% (N=3,465)
Renal Function (N=12,511) (N=3,776)
Normal 74.8% 69.1% Renal Dysfunction 14.9% 17.6% Creatinine>2.5 mg/dl 9.0% 10.4% Chronic Dialysis 1.2% 2.5% Renal Transplant 0.2% 0.4%
Hyperlipidemia
48.7% (N=13,183)
81.3% (N=3,899)
Diabetes 24.1% (N=12,487)
32.0% (N=3,444)
CAV 8.2% (N=11,260) 33.2% (N=2,376)
2002ISHLT
Freedom from CAV and Freedom from Renal Dysfunction*
For Adult Heart Recipients (April 1994-December 2000)
50
60
70
80
90
100
0 12 24 36 48 60 72 84
Months
% F
reed
om fr
om C
AV
or
Free
dom
fr
om R
enal
Dys
func
tion
Freedom from CAV
Freedom from Renal Dysfunction
* Renal dysfunction = Creatinine > 2.5 mg/dl, dialysis or renal transplant
2002ISHLT
MALIGNANCY POST-HEART TRANSPLANTATION FOR ADULTSCumulative Incidence for Survivors (April 1994-December 2001)
Malignancy/Type 1-Year Survivors 5-Year Survivors
No Malignancy 12,671 (96.6%) 3,203 (81.8%)
Malignancy (all types combined) 443 (3.4%) 712 (18.2%)
Malignancy Type
Skin 184 404
Lymph 107 63
Other 103 155
Lymph + Skin 8
Lymph + Other 13
Skin + Other 34
Lymph + Skin + Other 2
Type Not Reported 49 33
2002ISHLT
Freedom from MalignancyFor Adult Heart Recipients (April 1994-December 2000)
50
60
70
80
90
100
0 12 24 36 48 60
Months
% F
ree
from
Mal
igna
ncy
All malignancy Lymph Skin Other
2002ISHLT
ADULT HEART TRANSPLANTATION Risk Factors for CAV Within 3 Years (April 1994 - December 1998)
N=6,851
VARIABLE Odds Ratio
P-value
95% Confidence Interval
Male Recipient/
Female Donor 0.76 0.009 0.62 -0.94
Transplant Year: 1997 0.77 0.01 0.63 -0.94
2002ISHLT
ADULT HEART TRANSPLANTATION Risk Factors for CAV Within 3 Years (April 1994 - December 1998)
Continuous Factors
N=6,851
VARIABLE Odds Ratio p-value Recipient Age – linear 0.03
20 1.27 35 1.13 50 1.01 65 0.90
Donor Age - linear < 0.0001 20 0.74 35 1.12 50 1.71 65 2.59
2002ISHLT
ADULT HEART TRANSPLANTATION Risk Factors for CAV Within 3 Years (April 1994 - December 1998)
Continuous Factors
N=6,851
VARIABLE Odds Ratio p-value Center Volume – linear < 0.0001
5 Transplants/Year 0.82 10 Transplants/Year 0.84 50 Transplants/Year 1.13
100 Transplants/Year 1.61 Recipient BMI - linear 0.03
15 0.77 20 0.88 25 1.01 30 1.16 35 1.32
2002ISHLT
ADULT HEART TRANSPLANTATION Risk Factors for CAV Within 7 Years (April 1994 - December 1995)
N=2,546
VARIABLE Odds Ratio
P-value
95% Confidence Interval
Donor history of hypertension
1.71 0.003 1.20 -2.44
Donor cause of death: intracranial hemorrhage or stroke
0.76 0.03 0.58 -0.98
2002ISHLT
ADULT HEART TRANSPLANTATION Risk Factors for CAV Within 7 Years (April 1994 - December 1995)
Continuous Factors
N=2,546
VARIABLE Odds Ratio p-value Recipient Age – linear 0.002 Recipient Age - quadratic 0.02
20 0.78 35 1.07 50 1.01 65 0.66
Donor Age - linear < 0.0001 20 0.74 35 1.13 50 1.72 65 2.62
2002ISHLT
ADULT HEART TRANSPLANT RECIPIENTS: Cause of Death (1982-2001)
0%
20%
40%
60%
80%
100%
0-30 Days (N = 3,144)
31 Days - 1 Year (N = 2,934)
>1 Year - 3 Years (N = 1,925)
>3 Years - 5 Years (N = 1,363)
>5 Years (N = 2,831)
Per
cen
tag
e o
f d
eath
s
Other
Technical
Graft Failure - Other
Primary Graft Failure
Infection, Non-CMV
Acute Rejection
CMV
Malignancy, Other
Lymphoma
CAV
Timing of Death
2002ISHLT
ADULT HEART TRANSPLANTS RECIPIENTS: Cause of Death by Era: Deaths in 0-30 Days
0%
20%
40%
60%
80%
100%
1982-1986 (N = 126)
1987-1991 (N = 966)
1992-1996 (N = 1,377)
1997-2001 (N = 627)
Per
cent
age
of d
eath
s
Other
Technical
Graft Failure - Other
Primary Graft Failure
Infection, Non-CMV
Acute Rejection
CMV
Malignancy, Other
Lymphoma
CAV
Year of Transplant
2002ISHLT
ADULT HEART TRANSPLANTS RECIPIENTS: Cause of Death by Era: Deaths in 31 Days-1 Year
0%
20%
40%
60%
80%
100%
1982-1986 (N = 107)
1987-1991 (N = 1,012)
1992-1996 (N = 1,332)
1997-2001 (N = 483)
Per
cent
age
of d
eath
s
Other
Technical
Graft Failure - Other
Primary Graft Failure
Infection, Non-CMV
Acute Rejection
CMV
Malignancy, Other
Lymphoma
CAV
Year of Transplant
2002ISHLT
ADULT HEART TRANSPLANTS RECIPIENTS: Cause of Death by Era: Deaths in >1 Year - 3 Years
0%
20%
40%
60%
80%
100%
1982-1986 (N = 45)
1987-1991 (N = 713)
1992-1996 (N = 944)
1997-2001 (N = 218)
Per
cent
age
of d
eath
s
Other
Technical
Graft Failure
Primary Graft Failure
Infection, Non-CMV
Acute Rejection
CMV
Malignancy, Other
Lymphoma
CAV
Year of Transplant
2002ISHLT
ADULT HEART TRANSPLANTS RECIPIENTS: Cause of Death by Era: Deaths in >3 Years - 5 Years
0%
20%
40%
60%
80%
100%
1982-1986 (N = 35)
1987-1991 (N = 657)
1992-1996 (N = 656)
1997-2001 (N = 15)
Pe
rce
nta
ge
of
de
ath
s
Other
Technical
Graft Failure - Other
Primary Graft Failure
Infection, Non-CMV
Acute Rejection
CMV
Malignancy, Other
Lymphoma
CAV
Year of Transplant
2002ISHLT
ADULT HEART TRANSPLANTS RECIPIENTS: Cause of Death by Era: Deaths in >5 Years
0%
20%
40%
60%
80%
100%
1982-1986 (N = 469)
1987-1991 (N = 1,868)
1992-1996 (N = 478)
Pe
rce
nta
ge
of
de
ath
s
Other
Technical
Graft Failure - Other
Primary Graft Failure
Infection, Non-CMV
Acute Rejection
CMV
Malignancy, Other
Lymphoma
CAV
Year of Transplant