The Spanish Heart Transplant Registry is dedicated to annually updating its most crucial data. This article details the most significant clinical characteristics, treatments administered, and outcomes related to the survival of procedures conducted in 2022. Additionally, trends in these aspects since 2013 are explored.
In 2022, a total of 311 heart transplants were performed, representing a 3% increase from the previous year. No significant changes in demographic and clinical characteristics were observed compared to prior years, supporting trends identified over the past decade. These trends highlight a reduction in urgent procedures and an increase in the use of pre-transplant circulatory support, particularly with ventricular assist devices. Over the last decade, survival rates reached 81.4% at one year and 73.4% at three years, showing numerical improvements that, while not statistically significant, are promising.
These results lead the authors to assert that, over the past decade, stabilization has been observed in the characteristics of heart transplant procedures and their outcomes.
COMMENTARY:
The 2022 Spanish Heart Transplant Registry stands out compared to the two previous years for being entirely free from the impacts of the SARS-CoV-2 pandemic. This period translated only into a slight increase in the total number of transplant patients without affecting outcomes. Consequently, we can assert that the experience and resilience of the Spanish heart transplant system enabled it to overcome the challenges of the pandemic in terms of activity and outcomes.
Analysis of temporal trends reveals the consistency of heart transplantation in Spain regarding the characteristics of recipients, donors, surgical procedures, and immunosuppressive treatments.
In recent years in Spain, most heart transplant recipients are men, representing approximately 75% of cases, with an average age close to 50 years. Additionally, in over one-third of cases, these patients undergo transplants urgently, often relying on pre-transplant ventricular assist devices, with a plateau or slight reduction in the use of VA-ECMO. This significant reduction in urgent transplants over the last four years is a clear outcome of the changes in the waitlist inclusion criteria implemented in July 2017. Furthermore, in half of the cases, transplants are performed with donors typically considered suboptimal.
A notable feature, infrequently discussed among cardiologists but particularly relevant to surgeons, is the significant increase over time in the percentage of transplant patients with previous cardiac surgeries. A decade ago, this rate was 37%, and it has now risen significantly to 47%, meaning nearly half of today’s transplants are reoperations, a fact of great importance. The intrinsic technical complexity of a reoperation entails higher morbidity and mortality in cardiac surgery, and heart transplants are no exception. Unfortunately, the registry does not detail information about these reoperations, which are becoming more common in heart transplant surgery, at least in Spain. Further study of this aspect would be beneficial for additional insights.
In terms of recipients, there is a trend toward more selective patient criteria. These patients present lower rates of diabetes, reduced hyperbilirubinemia, and shorter mechanical ventilation times. Additionally, progressive reductions in ischemia times reflect the outstanding coordination and dedication of organ procurement teams.
With the recent implementation of the “Criteria for Heart Transplant Distribution in Spain 2023,” detailed in a recent blog post and effective April 1, 2023, the most significant change to date in prioritization criteria for heart transplants has been introduced. This change, born from a multidisciplinary consensus conference, primarily aims to prioritize patients in more critical clinical conditions, preventing them from reaching multi-organ failure thresholds and optimizing the efficient use of the scarce resource that is the donated organ. Only through continuous monitoring of clinical outcomes in the coming years can we conduct a thorough analysis to assess whether this modification has proven effective in balancing accessibility and futility in transplantation.
It is crucial to highlight initiatives aimed at expanding donor availability. First, the performance of ABO-incompatible heart transplants has increased, alleviating the shortage of pediatric donors. Furthermore, as previously discussed in blog posts, since late 2020, circulatory death donation has been implemented in nine centers in Spain, including our own. This approach is experiencing exponential growth and is set to significantly transform and expand the donor pool in our country.
Finally, it is highly likely that we have reached a peak in survival rates, slightly above 80% in the first year, as evidenced by the last decade’s analysis. However, further improvements are conceivable, potentially linked to the growing experience of newly incorporated groups in ventricular assist programs, the ongoing implementation of the recent organ distribution criteria, or the expansion of circulatory death donation. Each of these advances holds the promise of a miracle, reminding us that each heart transplant is a gift of life that provides a new opportunity to dream and live fully.
REFERENCE:
González-Vílchez F, Hernández-Pérez F, Almenar-Bonet L, Crespo-Leiro MG, López-Granados A, et al.; representing the Spanish Heart Transplant Teams. Spanish heart transplant registry. 34th official report of the Heart Failure Association of the Spanish Society of Cardiology. Rev Esp Cardiol (Engl Ed). 2023 Sep 6(23)00234-7. English, Spanish. doi: 10.1016/j.rec.2023.06.013.
