Infectious complications following heart transplantation in the era of high-priority allocation and extracorporeal membrane oxygenation

Abstract

BackgroundInfectious complications are a major cause of morbidity and mortality after heart transplantation (HT). However, the epidemiology and outcomes of these infections in the recent population of adult heart transplant recipients have not been investigated.MethodsWe conducted a single-center retrospective study on infectious complications occurring within 180 days following HT on consecutive heart transplant recipients, from January 2011 to June 2015 at Bichat University Hospital in Paris, France. Risk factors for non-viral infections occurring within 8, 30 and 180 days after HT were investigated using competing risk analysis.ResultsOverall, 113 patients were included. Fifty-eight (51%) HTs were high-priority allocations. Twenty-eight (25%) patients had an extracorporeal membrane oxygenation (ECMO) support at the time of transplantation. Ninety-two (81%) patients developed at least one infection within 180 days after HT. Bacterial and fungal infections (n = 181 episodes) occurred in 80 (71%) patients. The most common bacterial and fungal infections were pneumonia (n = 95/181 episodes, 52%), followed by skin and soft tissue infections (n = 26/181, 14%). Multi-drug-resistant bacteria were responsible for infections in 21 (19%) patients. Viral infections were diagnosed in 44 (34%) patients, mostly Cytomegalovirus infection (n = 39, 34%). In multivariate subdistribution hazard model, prior cardiac surgery (subdistribution hazard ratio sHR = 2.7 [95% CI 1.5–4.6] p < 0.01) and epinephrine or norepinephrine at the time of HT (sHR = 2.3 [95% CI 1.1–5.2] p = 0.04) were significantly associated with non-viral infections within 8 days after HT. Prior cardiac surgery (sHR = 2.5 [95% CI 1.4–4.4] p < 0.01), recipient age over 60 years (sHR = 2.0 [95% CI 1.2–3.3] p < 0.01) and ECMO following HT (sHR = 1.7 [95% CI 1.0–2.8] p = 0.04) were significantly associated with non-viral infection within 30 days after HT, as well as within 180 days after HT.ConclusionThis study confirmed the high rate of infections following HT. Recipient age, prior cardiac surgery and ECMO following HT were independent risk factors for early and late bacterial and fungal infections.Electronic supplementary materialThe online version of this article (10.1186/s13613-019-0490-2) contains supplementary material, which is available to authorized users.

Predictive risk factors for postoperative pneumonia after heart transplantation

“….Indeed, haemodynamic instability, low cardiac output and systemic inflammatory response syndrome induced during cardiac surgery can lead to intestinal ischaemia and bacterial [16]. Moreover, recipients with POP are assisted more by VA-ECMO in the postoperative period due to haemodynamic instability or low blood flow during the transplantation that may predispose patients to infections [10]. More than two-thirds of our recipients were assisted by VA-ECMO after transplantation, and although patients with postoperative pneumonia appeared to be more assisted, VA-ECMO does not appear to be a risk factor for POP.…”

“…More than two-thirds of our recipients were assisted by VA-ECMO after transplantation, and although patients with postoperative pneumonia appeared to be more assisted, VA-ECMO does not appear to be a risk factor for POP. Nosocomial infections, especially ventilator-associated pneumonia, are frequent in patients assisted by VA-ECMO [18], and HTx recipients assisted by VA-ECMO are known to develop nosocomial infections and pneumonia [10]. Moreover, the low cardiac output syndrome may explain the increased incidence of POP after HTx in comparison with conventional cardiac surgery (33.7% vs 5.7%), in which the incidence of intraand postoperative haemodynamic instability is less important [4].…”

“…Vidal et al BMC Anesthesiology (2020) 20:8 low cardiac output syndrome could contribute to digestive bacterial translocation and may influence the pathogens involved in early POP in HTx recipients. The association of increased incidence of POP and transfusion or reoperation for bleeding are additional arguments to explain the blood-forming origin of POP [10] and this unusual high rate of Enterobacteriaceae and Pseudomonas aeruginosa in POP after HTx. Transfusion per se is an additional process that is known to increase the rate of postoperative infections after the first transfusion of packed red blood cells [22] and to increase 28-day mortality [23].…”

“…In cardiac surgery, POP is still the most common infectious complication [4] and is known to be associated with increased mortality [5,6]. After HTx, the incidence and risk factors for POP remain poorly investigated [7][8][9][10]. In addition, plasmapheresis and intravenous immunoglobulins (IVIg) used to prevent antibody-mediated rejection in sensitized recipients may also influence the occurrence of POP after HTx [11][12][13].…”

Predictive risk factors for postoperative pneumonia after heart transplantation

“…(5,6) After HTx, the incidence and risk factors for POP remain poorly investigated. (7)(8)(9)(10)In addition, plasmapheresis and intravenous immunoglobulins (IVIg) used to prevent antibody-mediated rejection in sensitized recipients may also influence the occurrence of POP after HTx. (11)(12)(13)The aim of this study was to investigate the risk factors for POP in HTx recipients, with or without preformed donor-specific anti-HLA antibodies (pfDSA).…”