Outcomes in patients with cardiac amyloidosis undergoing heart transplantation: the eurotransplant experience

https://doi.org/10.1016/j.healun.2023.01.001Get rights and content

Background

When advanced heart failure occurs in cardiac amyloidosis, prognosis is poor. In this setting heart transplantation (HTX) is a treatment option for selected patients. We here present the results of post-transplantation outcomes in cardiac amyloidosis within the Eurotransplant area, investigating possible predictors of survival.

Methods

Of 115 patients undergoing HTX due to cardiac amyloidosis in the Eurotransplant region between November 1987 and May 2020, detailed assessment prior to transplantation was available in 85 patients. The present study was conducted in a retrospective approach. Primary endpoint was mortality after HTX. Baseline variables were entered in a Cox proportional hazards model with the primary endpoint as a dependent variable.

Results

Median overall survival following HTX was 6.3 years in the overall collective and the subgroup. Univariate Cox proportional hazards model revealed a significant relationship between overall survival and the transplantation period (2008 to 2020 vs 1987 to 2007; median survival 9.7 years vs 1.8 years, hazard ratio 0.45, p = 0.01). Further predictors were albumin concentration (hazard ratio 0.92, p < 0.001), and systolic blood pressure (hazard ratio 0.96, p < 0.001). The transplant period as well as albumin concentration remained significant independent predictors in the AL sub cohort in a multivariate Cox proportional hazards model.

Conclusions

HTX is a viable treatment option for patients at an advanced stage of cardiac amyloidosis as overall survival after transplantation has improved in the modern age. Patients at a very advanced stage of the disease, indicated by low serum albumin and blood pressure, show worse outcomes following HTX. Optimal timing and careful patient selection may therefore be particularly important to further improve post-HTX survival in amyloidosis patients.

Section snippets

Methods

The study conforms with the principles outlined in the Declaration of Helsinki, as well as the ISHLT statement on transplant ethics22,23 and was conducted in a retrospective approach. Patient data was provided by Eurotransplant as collected in the Eurotransplant registry. The Eurotransplant registry gathers information on all patients listed for HTX in the Eurotransplant region through reports from each transplant centre.

Survival following HTX

Median overall survival following HTX for all patients (n = 115) was 2228 days (6.3 years), Figure 1) and also 6.3 years in the subgroup of 85 patients with more detailed information. Fifty-four patients (39%) died within the study period. Median survival was numerically longer in ATTR amyloidosis patients (4447 days, 12.2 years) than in AL amyloidosis patients (1631 days, 4.5 years). However, there was no statistically significant difference in survival between both amyloidosis subtypes (p

Discussion

We here present one of the largest cohorts of patients with heart transplantations due to cardiac amyloidosis.14,15,18,19 Moreover, our study is the first multinational one demonstrating that HTX for cardiac amyloidosis is a feasible treatment option. Besides, the relatively high number of patients allows for the first time the identification of potential factors in this patient group that can be correlated with patient survival after HTX. Thus, we do not only present HTX as a feasible

Conclusion

When amyloid cardiomyopathy turns into advanced heart failure, treatment options are very limited. Heart transplantation is safe, feasible and can approach survival seen in non-amyloid patients. This needs to be taken into special consideration in view of the great advancements in the treatment of advanced heart failure in recent years – knowing that these new therapeutic options showed little effect on amyloidosis patients. Yet, careful patient selection and contemporary therapy strategies for

Authors' Contribution

Martin J. Kraus: Conceptualization, Methodology, Formal analysis, Investigation, Data Curation, Writing, Visualization, Supervision. Jacqueline M. Smits: Supervision, Investigation, Resources, Methodology, Validation. Anna L. Meyer: Investigation, Review. Agita Strelniece: Resources, Investigation. Arne van Kins: Resources, Investigation. Udo Boeken: Investigation, Review. Alexander Reinecke: Investigation, Review. Zdenek Provaznik: Investigation, Review. Oliver Van Caenegem: Investigation.

Disclosure statement

The authors have no conflicts of interest to disclose. This manuscript received no funding.

Acknowledgments

We would like to thank Myriam Wittek and André Hochgesand for assistance with data acquisition and analysis.

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