**5. Patient selection for cardiac re-transplantation**

The Consensus Conference on Retransplantation was sponsored by the American Society of Transplantation, the American Society of Transplant Surgeons, and the National Institute of Allergy and Infectious Diseases and was held in Atlanta in 2006 and outlined several important considerations for ReTx candidacy [6]. The working group concluded that patients undergoing ReTx should have either chronic graft failure in the absence of active rejection, or severe CAV not amenable to medical or surgical therapy. Additionally they suggested that patients with CAV should have either symptoms attributable to CAV or moderate to severe left ventricular dysfunction. Additionally, they proposed that patients with graft failure due to ongoing acute rejection, especially less than 6 months post-transplant, be ineligible for ReTx. In addition to considerations regarding the indication for ReTx, there are several other patient factors that warrant discussion given their strong associations with survival following ReTx.

Patient selection is a key component for improving short and long-term survival following ReTx. A summary of factors known to be associated with patient outcomes is presented in **Table 4**. Long-term survival is strongly driven by age at time of ReTx, as evidenced by relatively good outcomes seen in pediatric populations. Given the impact of age on survival, some groups have questioned the efficacy of ReTx in patients over the age of 60 years [6]. Patients undergoing ReTx have longer exposure to immunosuppression which may explain a possible increase in the risk of infections and malignancies; [28] therefore, careful attention should be given to excluding infection or occult malignancy when assessing ReTx candidacy. Poor renal function is also more common in ReTx patients and is associated with increased mortality. In a cohort of ReTx patients from Stanford, patients with creatinine >2.0 mg/dL had worse short-term outcomes, while patients undergoing simultaneous heart and kidney transplant had improved survival [14]. Similarly, patients on hemodialysis undergoing initial cardiac transplant in the UNOS database had better survival when undergoing simultaneous


**Table 4.** Summary of predictors associated with patient outcomes.

heart-kidney transplant compared heart transplant alone [29]. Therefore, poor renal function should be considered a relative contraindication to ReTx unless the patient is a candidate for simultaneous heart-kidney transplant.

the improved proportional survival of pediatric ReTx patients compared to adult cohorts, it is

The Consensus Conference on Retransplantation was sponsored by the American Society of Transplantation, the American Society of Transplant Surgeons, and the National Institute of Allergy and Infectious Diseases and was held in Atlanta in 2006 and outlined several important considerations for ReTx candidacy [6]. The working group concluded that patients undergoing ReTx should have either chronic graft failure in the absence of active rejection, or severe CAV not amenable to medical or surgical therapy. Additionally they suggested that patients with CAV should have either symptoms attributable to CAV or moderate to severe left ventricular dysfunction. Additionally, they proposed that patients with graft failure due to ongoing acute rejection, especially less than 6 months post-transplant, be ineligible for ReTx. In addition to considerations regarding the indication for ReTx, there are several other patient factors that warrant discussion given their strong associations with

Patient selection is a key component for improving short and long-term survival following ReTx. A summary of factors known to be associated with patient outcomes is presented in **Table 4**. Long-term survival is strongly driven by age at time of ReTx, as evidenced by relatively good outcomes seen in pediatric populations. Given the impact of age on survival, some groups have questioned the efficacy of ReTx in patients over the age of 60 years [6]. Patients undergoing ReTx have longer exposure to immunosuppression which may explain a possible increase in the risk of infections and malignancies; [28] therefore, careful attention should be given to excluding infection or occult malignancy when assessing ReTx candidacy. Poor renal function is also more common in ReTx patients and is associated with increased mortality. In a cohort of ReTx patients from Stanford, patients with creatinine >2.0 mg/dL had worse short-term outcomes, while patients undergoing simultaneous heart and kidney transplant had improved survival [14]. Similarly, patients on hemodialysis undergoing initial cardiac transplant in the UNOS database had better survival when undergoing simultaneous

**Associated with worse patient outcomes Associated with improved patient outcomes**

Primary/acute graft failure Lack of peripheral vascular disease

Ischemic cardiomyopathy CAV/Chronic graft failure

Shorter interval between initial transplant and ReTx (<6 months) Younger age

likely that outcomes will also be acceptable in the younger adult population.

**5. Patient selection for cardiac re-transplantation**

survival following ReTx.

204 Heart Transplantation

Renal dysfunction (Creatinine >2.0 mg/dL)

**Table 4.** Summary of predictors associated with patient outcomes.

Multiple previous sternotomies Requiring ICU care pre-operatively The number of previous sternotomies should also be considered when deciding if a patient is a candidate for ReTx. Multiple previous sternotomies from prior palliative congenital procedures or coronary artery bypass grafting adds to the burden of scar tissue, in addition to potentially complicated anastamotic sites from the initial transplant. Some authors have argued that this contributes to the high rates of multi-system organ failure in patients after ReTx, as well as high rates of early mortality [18, 28]. These findings are attributed to an increased incidence of mediastinitis, intrathoracic bleeding requiring reintervention, and primary graft failure [30]. These findings have also been seen in pediatric ReTx, many of which have had previous palliative procedures [26]. Lastly, patients admitted to ICU prior to ReTx, and particularly those requiring mechanical circulatory support, have worse outcomes [31]. In these patients it is important to not only ensure that organ dysfunction is reversible, but also that the patient will be capable of undergoing rehabilitation if the operation is successful. Consideration of these factors may help identify patients with the greatest potential benefit from ReTx.

Patients undergoing ReTx are more highly sensitized than patients undergoing initial cardiac transplant [5]. Higher sensitization increases the risk of CAV, acute rejection and posttransplant mortality [32, 33]. Therefore, it may be necessary to consider options to desensitize patients prior to ReTx in order to improve the chance of successful graft matching as well as improving outcomes following ReTx.
