Should Age-Based Eligibility Thresholds Differ for Repeat Heart Transplantation? Analysis of the United Network of Organ Sharing Database

Purpose Risk-adjusted survival after cardiac re-transplantation may be comparable to primary transplant, but the efficacy of re-transplantation in older candidates is not established. We evaluated outcomes after re-transplantation in recipients > 60 years. Methods The United Network for Organ Sharing Database identified 1295 adult patients undergoing heart re-transplants between 2003 and 2020 (excluding heart-lung transplants). Unadjusted 5-year survival of older recipients (> 60 years, n=212) was compared to younger recipients (<= 60 years, n=1083). Adjusted Cox model using restricted cubic splines explored the non-linear relationship between recipient age and mortality risk after re-transplantation. A separate multivariate Cox model analyzed recipients>60 years undergoing either primary transplant (n=12826) or re-transplantation (n=181, excluding re-transplants for acute/hyperacute rejection or primary graft dysfunction) to evaluate the impact of re-transplantation on mortality. Results In patients undergoing re-transplantation, older recipients had more pre-transplant ECMO use (9.9% vs. 5.8%, p=0.027) and received grafts from older donors (34, IQR 24-46 vs. 28, IQR 21-38 years, p<0.0001). Recipient age >60 was associated with inferior unadjusted survival (Figure 1A). Restricted cubic spline (Figure 1B) showed a significant increase in mortality risk when recipient age becomes older than 61.8 years (corresponding HR 1.35, 95% CI 1.01-1.79). In recipients >60 years undergoing either primary transplant or re-transplantation, re-transplantation was independently associated with increased risk of mortality (HR 1.33, 95% CI 1.07-1.65, p=0.01) compared to primary transplant. Conclusion Re-transplanting patients greater than 60 years old is independently associated with increased risk of mortality. More conservative age-based thresholds for re-transplantation may be appropriate. Risk-adjusted survival after cardiac re-transplantation may be comparable to primary transplant, but the efficacy of re-transplantation in older candidates is not established. We evaluated outcomes after re-transplantation in recipients > 60 years. The United Network for Organ Sharing Database identified 1295 adult patients undergoing heart re-transplants between 2003 and 2020 (excluding heart-lung transplants). Unadjusted 5-year survival of older recipients (> 60 years, n=212) was compared to younger recipients (<= 60 years, n=1083). Adjusted Cox model using restricted cubic splines explored the non-linear relationship between recipient age and mortality risk after re-transplantation. A separate multivariate Cox model analyzed recipients>60 years undergoing either primary transplant (n=12826) or re-transplantation (n=181, excluding re-transplants for acute/hyperacute rejection or primary graft dysfunction) to evaluate the impact of re-transplantation on mortality. In patients undergoing re-transplantation, older recipients had more pre-transplant ECMO use (9.9% vs. 5.8%, p=0.027) and received grafts from older donors (34, IQR 24-46 vs. 28, IQR 21-38 years, p<0.0001). Recipient age >60 was associated with inferior unadjusted survival (Figure 1A). Restricted cubic spline (Figure 1B) showed a significant increase in mortality risk when recipient age becomes older than 61.8 years (corresponding HR 1.35, 95% CI 1.01-1.79). In recipients >60 years undergoing either primary transplant or re-transplantation, re-transplantation was independently associated with increased risk of mortality (HR 1.33, 95% CI 1.07-1.65, p=0.01) compared to primary transplant. Re-transplanting patients greater than 60 years old is independently associated with increased risk of mortality. More conservative age-based thresholds for re-transplantation may be appropriate.