Emergency and elective cardiac retransplantation

Abstract

Among 265 patients transplanted at our Institution, 7 underwent cardiac retransplantation. There were five emergency retransplantations, the indication being graft failure in one case and acute rejection in four cases. Two patients, retransplanted because of acute rejection, had a positive panel reactivity antibody and a negative donor crossmatch. In the rejection cases immunosuppression was enhanced by perioperative plasmapheresis and a postoperative 1-month course of cyclophosphamide. In two cases emergency retransplantations were successfully performed despite a highly positive prospective crossmatch. Two patients underwent elective retransplantations for chronic rejection 12 and 41 months, respectively, after the primary transplants. The overall early and late survival rates are 71% and 57%, respectively, with a mean follow-up of 48.5 months. The early and late mortality for elective retransplantation is zero. Our experience confirms both the high operative risk for emergency retransplantation and the excellent results for elective retransplantation. The use of plasmapheresis and cyclophosphamide allowed us to undertake retransplantation successfully in 2 cases with positive donor crossmatch. Both hyperimmunized patients in our series were retransplanted because of irreversible acute rejection despite a negative crossmatch with the primary donor. The meaning of negative crossmatch in patients with preformed cytotoxic antibodies is therefore questionable.

Should we perform heart retransplantation in early graft failure?

“…Although different surgical and medical options have been proposed to overcome end-stage heart failure, such as coronary artery bypass graft (CABG) surgery, partial left ventriculoplasty, coronary angioplasty, laser myocardial therapy, mechanical assistance and new pharmacologic regimens [5][6][7][8][9][10], heart retransplantation remains the only therapy which can achieve the long-term survival of these patients. Since the first case, performed by Copeland and colleagues in 1977 [11], several centers have reported their results on cardiac retransplantation [4,[12][13][14][15][16][17]. From our experience, the overall survival of cardiac retransplantation was significantly lower compared with that of primary transplantation (P < 0.001).…”

“…Our statistical analysis of the risk factors affecting outcome after cardiac retransplantation showed that only early graft failure ( P = 0.02) was an independent predictor of mortality after retransplantation. Although in these cases the only chance for survival could be a salvage retransplantation, the poor outcome in this subgroup of patients calls into question whether or not it is justifiable to use resources and precious organs for patients with EGF [4,14]. A hypothetical solution for these patients, especially in the context of lack of donors, could be to use a ventricular assist device (VAD) as a bridge to retransplantation.…”

“…In case of chronic rejection the operation can usually be programmed electively, on hemodynamically stable and metabolically balanced recipients. The context is different in case of early graft failure, because of the fact that patients are usually clinically compromised, often with inotropic or mechanical support, and retransplantation is frequently performed in emergency conditions [4]. With these concerns in mind, we retrospectively reviewed our Summary Cardiac retransplantation represents the gold standard treatment for a failing cardiac graft but the decision to offer the patient a second chance is often made difficult by both lack of donors and the ethical issues involved.…”

Cardiac transplantation across a positive prospective lymphocyte cross‐match in sensitized recipients

“…For example, Martinelli et al. questioned the meaning of a negative cross‐match in two patients with preformed cytotoxic antibodies whose primary OHT was complicated by irreversible acute rejection (49). In two other cases, emergency re‐transplantations were successfully performed despite a highly positive prospective cross‐match.…”

“…In addition, subsequent studies also identified poor outcomes in terms of earlier rejection and shorter survival of such patients (2, 3, 7–10). On the other hand, many studies have reported no ill effect on the outcome of heart transplantation to be associated with such test results (10–15). Finally, a few reports have reported a beneficial association (16, 17).…”