A foregone conclusion? The association between early hospital course and late outcomes in modern era heart transplant

Abstract

Objectives

The revised US donor heart allocation policy allows for transplantation in more critically ill patients with heart failure. This study examines the association between index hospitalization and 1-year functional outcomes in the modern era.

Methods

All adult, single-organ heart transplant recipients at a single institution from October 2018 to January 2023 were retrospectively reviewed. Multistate Cox regression identified predictors of death in hospital or prolonged length of stay. Length of stay was then associated with 1-year Karnofsky Performance score, chronic dialysis, readmission, and mortality.

Results

A total of 441 patients were stratified into a death in hospital group (n = 28) and short (≤30 days, n = 341), medium (30-60 days, n = 59), and long (≥60 days, n = 16) length of stay groups. Short index length of stay is associated with higher 1-year performance status scores and lower rates of chronic dialysis and readmissions compared with medium and long length of stay groups, as well as superior 1-year survival compared with the long length of stay group. Congenital and graft failure etiology, pretransplant left ventricular assist device, post-transplant extracorporeal membrane oxygenation, and post-transplant dialysis were independent predictors of death in hospital. Pretransplant left ventricular assist device, hypertension, poor baseline renal function, post-transplant extracorporeal membrane oxygenation, and post-transplant dialysis were risk factors for prolonged hospitalization.

Conclusions

Both preoperative recipient characteristics and early outcomes are predictive of in-hospital mortality or prolonged length of stay after heart transplant. Longer length of stay is associated with inferior 1-year functional outcomes and mortality. This study suggests the need for interventions targeted toward high-risk patients to improve early and late outcomes.