The evolving risk of sudden cardiac death after heart transplant. An analysis of the ISHLT Thoracic Transplant Registry

Abstract

Sudden cardiac death (SCD) is responsible for ~10% of post-heart transplant deaths.We conducted a retrospective analysis of the ISHLT registry evaluating the risk of post-transplant SCD. Adult heart transplant recipients (2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014) surviving the first year were included. We used multivariable multistate competing risk survival analysis to evaluate the impact of history of treated rejection and cardiac allograft vasculopathy (CAV) on SCD risk. We used a probabilistic analytical model and MonteCarlo simulation to estimate the impact of CAV severity and graft dysfunction on SCD. We included 25 242 recipients. During a median follow-up of 4.7 (2.3-7.0) years, 582 patients died suddenly. Treated rejection (HR 1.76, 95% CI 1.36-2.31) and CAV (HR 3.32, 95% CI 2.73-4.03) were important risk factors for SCD. The estimated SCD risk in patients with severe CAV without and with graft dysfunction was 3.2% (95% CI 2.0-4.6) and 5.4% (95% CI 3.8-7.0), respectively, at 2 years from the CAV diagnosis, and 4.9% (95% CI 3.4-6.5) and 8.0% (95% CI 6.1-10.0), respectively, in those who also had treated rejection. These results provide evidence that recipients with severe CAV and graft dysfunction or treated rejection are at clinically significant increased SCD risk. The benefit of ICD post-transplant remains uncertain. K E Y W O R D Scardiac allograft vasculopathy, heart transplant, rejection, risk, sudden cardiac death

Implantable cardioverter defibrillators in patients with orthotopic heart transplant: A multicenter case series

“…Cardiac transplantation is the gold standard in the treatment of chronic stage D heart failure refractory to heart failure guideline‐directed medical therapy 11 . SCD is a common cause of death in patients after OHT, reported at 0.7%, 12 2.3%, 12 and 10% 1 over a follow‐up of 1 year, 12 4.7 years, 12 and 6.5 years, 1 respectively. While the incidence of overall and non‐SCD posttransplantation mortality has decreased, SCD mortality has not 1 .…”

Trasplante cardiaco y bloqueo auriculoventricular tardío. Reporte de un caso

“…Aun cuando en estudios previos se ha reportado con mayor proporción asistolia o actividad eléctrica sin pulso asociada a la muerte súbita en pacientes postrasplante cardiaco (34 y 20%, respectivamente), la fibrilación ventricular puede identificarse en el 6-10% de los casos, encontrándose como factores de riesgo asociados a su presentación el antecedente de rechazo, vasculopatía y disfunción del injerto, hallazgos que en conjunto se han relacionado con una mayor incidencia de descargas apropiadas en pacientes con trasplante cardiaco llevados a implante de CDI, y que condicionan un riesgo de muerte súbita que ha sido considerado comparable al de los pacientes con falla cardiaca con fracción de eyección reducida, lo cual en nuestro caso motivó el implante de un CDI para prevención primaria de muerte súbita 6 , 7 .…”

Current status and outcomes in heart transplantation: a narrative review

“…Donorderived CAD does not seem to accelerate progression of CAV [50]. Although CAV is associated with sudden cardiac death and with lower survival rates at 3 and 10 years post-HTx, especially if developed within the first year, CAV rates and survival have generally improved [3,118,123]. Among HTx recipients who die anytime after 1 year post-HTx, cause of death due to CAV is estimated to be 10.5-12.4% [3].…”

“…Donor ischemic time does not seem to affect rejection-related mortality after HTx [52]. While history of treated rejection episodes within 1-year post-transplant is known to be associated with sudden cardiac death [118], asymptomatic AMR does not affect actuarial 5-year survival [119]. However, overall AMR is associated with an 8% incremental increase in cardiovascular mortality per episode [120].…”