title: Mechanical circulatory support and simultaneous heart-kidney transplantation: An outcome analysis.
abstract: BACKGROUND
  Single-donor simultaneous heart-kidney transplantation (SHKT) can significantly improve the survival of those with advanced heart failure and advanced renal insufficiency. Data on pre-transplant use of mechanical circulatory support (MCS) devices and outcomes after SHKT are limited and conflicting.
  
  
  METHODS
  Using the United Network for Organ Sharing registry data, we evaluated 749 adults undergoing SHKT after January 1, 2000. Patients were categorized into the following groups according to their type of pre-transplant MCS device: none (n = 568), pulsatile-flow left (n = 28), continuous-flow left (n = 68), temporary (n = 12), biventricular (n = 19), total artificial heart (n = 20), and unknown (n = 34). Regression analyses were performed to assess the association between types of MCS and post-transplant outcomes.
  
  
  RESULTS
  Pre-transplant MCS was not associated with in-hospital mortality (univariate odds ratio [OR], 1.57; 95% confidence interval [CI], 0.82-2.97; p = 0.170) or post-discharge mortality (univariate hazard ratio, 0.92; 95% CI, 0.58-1.47; p = 0.733). Patients supported with pre-transplant temporary MCS devices were more likely to suffer from serious complications (composite of cardiac or non-cardiac surgeries, stroke, any drug-treated infection, and permanent pacemaker; multivariable adjusted OR, 10.0; 95% CI, 2.77-36.0; p < 0.001) after SHKT. Pre-transplant MCS did not increase risk of post-transplant dialysis (multivariable adjusted OR, 1.19; 95% CI, 0.81-1.75; p = 0.375) or cardiac rejection (univariate OR, 0.71; 95% CI, 0.34-1.51; p = 0.382), and did not prolong the length of hospital stay (≥ 4 weeks; multivariable adjusted OR, 1.05; 95% CI, 0.69-1.59; p = 0.832). Post-transplant dialysis status was a major determinant of adverse in-hospital (multivariable adjusted OR, 6.17; 95% CI, 3.14-12.1; p < 0.001) and post-discharge (multivariable adjusted hazard ratio, 1.56; 95% CI, 1.02-2.39; p = 0.041) mortality after SHKT.
  
  
  CONCLUSIONS
  In the current transplant era, survival after SHKT in patients with pre-transplant MCS was equivalent to that of conventional SHKT. Pre-transplant dialysis, and not MCS status, determined the need for post-SHKT dialysis, which in-turn was a major risk factor for in-hospital and long-term mortality.
authors.affiliation: Department of Advanced Heart Failure and Transplant Cardiology, Nashville, Tennessee. Electronic address: sandip.zalawadiya@gmail.com.
authors.forename: Sandip K
authors.initials: SK
authors.lastname: Zalawadiya
authors.affiliation: Department of Advanced Heart Failure and Transplant Cardiology, Nashville, Tennessee.
authors.forename: Mark
authors.initials: M
authors.lastname: Wigger
authors.affiliation: Department of Advanced Heart Failure and Transplant Cardiology, Nashville, Tennessee.
authors.forename: Thomas
authors.initials: T
authors.lastname: DiSalvo
authors.affiliation: Department of Advanced Heart Failure and Transplant Cardiology, Nashville, Tennessee.
authors.forename: Nicholas
authors.initials: N
authors.lastname: Haglund
authors.affiliation: Division of Cardiovascular Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
authors.forename: Simon
authors.initials: S
authors.lastname: Maltais
authors.affiliation: Department of Advanced Heart Failure and Transplant Cardiology, Nashville, Tennessee.
authors.forename: JoAnn
authors.initials: J
authors.lastname: Lindenfeld
mesh_terms: D005260:Female; D016027:Heart Transplantation / Q000379:methods* / Q000401:mortality; D006353:Heart-Assist Devices; D006801:Humans; D016030:Kidney Transplantation / Q000379:methods* / Q000401:mortality; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D012044:Regression Analysis; D006435:Renal Dialysis; D016896:Treatment Outcome
keywords: heart failure; heart-kidney transplantation; mechanical circulatory support; post-transplant outcome; pre-transplant; renal insufficiency