Heart-Lung Transplantation in Adult Recipients: Insights from 2017

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Explore the latest findings on heart-lung transplantation in adult recipients from the 2017 Journal of Heart and Lung Transplantation. Discover donor and recipient characteristics, post-transplant outcomes, immunosuppression strategies, morbidities, and more. Gain valuable insights into the number of transplants reported, average center volume by location, retransplants, and diagnoses over the years. Stay informed with in-depth analyses and a focus on key themes in heart-lung transplantation.

  • Heart-Lung Transplantation
  • Adult Recipients
  • Post-transplant Outcomes
  • Immunosuppression
  • Recipient Characteristics
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  1. HEART-LUNG TRANSPLANTATION Adult Recipients 2017 JHLT. 2017 Oct; 36(10): 1037-1079

  2. Table of Contents Donor and recipient characteristics: slides 3-13 Post transplant survival and other outcomes: slides 14-23 Induction and maintenance immunosuppression: slides 24-29 Post transplant morbidities: slides 30-38 Multivariable analyses: slides 39-42 Focus theme: slides 43-54 2017 JHLT. 2017 Oct; 36(10): 1037-1079

  3. Donor and Recipient Characteristics 2017 JHLT. 2017 Oct; 36(10): 1037-1079

  4. Adult Heart-Lung Transplants Number of Transplants Reported by Year 300 250 Number of Transplants 200 150 100 50 0 NOTE: This figure includes only the heart-lung transplants that are reported to the ISHLT Transplant Registry. As such, this should not be construed as evidence that the number of heart-lung transplants worldwide has declined in recent years. 2017 JHLT. 2017 Oct; 36(10): 1037-1079

  5. Adult Heart-Lung Transplants Average Center Volume by Location (Transplants: January 2009 June 2016) Europe North America Other Percentage of Transplants 60 42 50 35 8 Number of Centers % of Transplants 40 28 23 30 21 4 20 14 7 23 10 7 0 0 12 2 1 3 3 3 0 0 1 2 4 - 9 Average number of heart-lung transplants per year 2017 JHLT. 2017 Oct; 36(10): 1037-1079

  6. Adult Heart-Lung Retransplants Retransplants by Year and Location Europe North America Other % of Retransplants 6 18 % of Retransplants out of All Adult 16 5 Heart-Lung Transplants 14 Number of Retransplants 4 12 10 3 8 2 6 4 1 2 0 0 2017 JHLT. 2017 Oct; 36(10): 1037-1079

  7. Adult Heart-Lung Transplants Diagnosis (Transplants: January 1982 June 2016) Diagnosis N (%) PH-not IPAH 1,204 (37.5%) IPAH 953 (29.7%) CF 462 (14.4%) COPD 141 (4.4%) IIP 113 (3.5%) A1ATD 63 (2.0%) Sarcoidosis 58 (1.8%) ILD-not IIP 47 (1.5%) Retransplant 42 (1.3%) Non CF-bronchiectasis 33 (1.0%) OB 23 (0.7%) Other 74 (2.3%) 2017 JHLT. 2017 Oct; 36(10): 1037-1079

  8. Adult Heart-Lung Transplants Diagnosis by Era (Transplants: January 1982 June 2016) 100% Other 90% Retransplant 80% Non CF- bronchiectasis 70% % of Transplants IIP 60% COPD 50% A1ATD 40% 30% CF 20% IPAH 10% PH-not IPAH 0% 2004-6/2016 (N=717) 1994-2003 (N=1,251) 2017 1982-1993 (N=1,245) JHLT. 2017 Oct; 36(10): 1037-1079

  9. Adult Heart-Lung Transplants Major Indications by Year (%) PH-not IPAH IPAH CF COPD IIP 100 90 80 % of Transplants 70 60 50 40 30 20 10 0 Transplant Year 2017 Since only major indications are shown, sum of percentages for each year is less than 100%. JHLT. 2017 Oct; 36(10): 1037-1079

  10. Adult Heart-Lung Transplants Major Indications by Year (Number) PH-not IPAH IPAH CF COPD IIP 180 160 Number of Transplants 140 120 100 80 60 40 20 0 Transplant Year 2017 JHLT. 2017 Oct; 36(10): 1037-1079

  11. Adult Heart-Lung Transplants Age Distribution by Location (Transplants: January 2004 June 2016) 18-34 35-49 50-59 60+ 100% 80% % of Transplants 60% 40% 20% 0% Europe North America Other 2017 JHLT. 2017 Oct; 36(10): 1037-1079

  12. Adult Heart-Lung Transplants Diagnosis Distribution by Location (Transplants: January 2004 June 2016) 100% Other 90% Retransplant 80% Non CF- bronchiectasis IIP 70% % of Transplants 60% COPD 50% A1ATD 40% CF 30% 20% IPAH 10% PH-not IPAH 0% Europe North America Other 2017 JHLT. 2017 Oct; 36(10): 1037-1079

  13. Adult Heart-Lung Transplants Donor Age Distribution by Location (Transplants: January 2004 June 2016) 6-11 12-17 18-34 35-49 50-59 60+ 100% 80% % of Donors 60% 40% 20% 0% Europe North America Other 2017 JHLT. 2017 Oct; 36(10): 1037-1079

  14. Post Transplant Survival and Other Outcomes 2017 JHLT. 2017 Oct; 36(10): 1037-1079

  15. Adult Heart-Lung Transplants Kaplan-Meier Survival (Transplants: January 1982 June 2015) 100 Median survival = 3.3 years Conditional median survival = 10.3 years 75 N = 3,953 Survival (%) 50 25 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Years 2017 JHLT. 2017 Oct; 36(10): 1037-1079

  16. Adult Heart-Lung Transplants Kaplan-Meier Survival by Transplant Type (Transplants: January 1982 June 2015) 100 Primary (N=3,868) First Retransplant (N=46) 75 Median survival (years): Primary: 3.4; Conditional=10.2; Retransplant: 0.2; Conditional=11.2 Survival (%) 50 p = 0.0088 25 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Years 2017 JHLT. 2017 Oct; 36(10): 1037-1079

  17. Adult Heart-Lung Transplants Kaplan-Meier Survival by Era (Transplants: January 1982 June 2015) 100 Median survival (years): 1982-1993=2.1; 1994-2003=3.7; 2004-6/2015=5.8; Conditional median survival (years): 1982-1993=9.0; 1994-2003=11.2; 2004-6/2015=NA 75 1982-1993 (N=1,600) Survival (%) 1994-2003 (N=1,427) 50 2004-6/2015 (N=926) 25 1982-1993 vs. 1994-2003: p<0.0001 1982-1993 vs. 2004-6/2015: p<0.0001 1994-2003 vs. 2004-6/2015: p=0.0539 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Years 2017 JHLT. 2017 Oct; 36(10): 1037-1079

  18. Adult Heart-Lung Transplants Kaplan-Meier Survival by Diagnosis (Transplants: January 1990 June 2015) 100 PH-not IPAH (N=1,022) CF (N=377) IIP (N=86) IPAH (N=725) COPD (N=102) 75 Median survival (years): PH-not IPAH=4.8; IPAH=4.4; CF=6.2; COPD=2.7; IIP=2.1 Survival (%) 50 25 No pair-wise comparisons were significant at p < 0.05 except CF vs. COPD 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Years 2017 JHLT. 2017 Oct; 36(10): 1037-1079

  19. Adult Heart-Lung Transplants Kaplan-Meier Survival by Diagnosis Conditional on Survival to 1 Year (Transplants: January 1990 June 2015) 100 PH-not IPAH (N=649) CF (N=264) IIP (N=53) IPAH (N=490) COPD (N=61) 75 Survival (%) 50 No pair-wise comparisons were significant at p < 0.05 25 Median survival (years): PH-not IPAH=12.3; IPAH=10.1; CF=11.8; COPD=7.3; IIP=7.3 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Years 2017 JHLT. 2017 Oct; 36(10): 1037-1079

  20. Adult Heart-Lung Transplants Functional Status of Surviving Recipients (Follow-ups: March 2005 June 2016) 100% 10% 20% 80% 30% 40% 60% 50% 60% 40% 70% 80% 20% 90% 100% 0% 1 Year (N=238) 2 Year (N=201) 3 Year (N=171) 2017 JHLT. 2017 Oct; 36(10): 1037-1079

  21. Adult Heart-Lung Transplants Surviving Recipients Working Post-Transplant (Follow-ups: January 2009 June 2016) 70% 60% 50% 40% 30% 20% 10% 0% 1 Year (N=466) 3 Years (N=355) 5 Years (N=311) 2017 JHLT. 2017 Oct; 36(10): 1037-1079

  22. Adult Heart-Lung Transplants Surviving Recipients Working Post-Transplant by Era (Follow-ups: April 1994 June 2016) 70% 60% 50% 40% 30% 20% 10% 0% 1 Year (N=240) 3 Years (N=190) 5 Years (N=173) 1 Year (N=226) 3 Years (N=165) 5 Years (N=138) 4/1994-2003 2004-6/2016 2017 JHLT. 2017 Oct; 36(10): 1037-1079

  23. Adult Heart-Lung Transplants Rehospitalization Post-transplant of Surviving Recipients (Follow-ups: April 1994 June 2016) 100% 80% 60% 40% No Hospitalization Hospitalized, Rejection Only Hospitalized, Rejection and Infection Hospitalized, Not Rejection/Not Infection Hospitalized, Infection Only 20% 0% Up to 1 Year (N=585) Between 2-3 Years (N=429) Between 4-5 Years (N=372) 2017 JHLT. 2017 Oct; 36(10): 1037-1079

  24. Induction and Maintenance Immunosuppression 2017 JHLT. 2017 Oct; 36(10): 1037-1079

  25. Adult Heart-Lung Transplants Induction Immunosuppression (Transplants: April 1994 June 2016) 70 60 50 % of Patients 40 30 20 10 0 Any Induction (N=172) Polyclonal ALG/ATG (N=47) IL-2R Antagonist (N=103) 2017 Analysis is limited to patients who were alive at the time of the discharge. JHLT. 2017 Oct; 36(10): 1037-1079

  26. Adult Heart-Lung Transplants Induction Immunosuppression by Year (Transplants: January 2004 December 2015) 100 Any induction Polyclonal ALG/ATG IL-2R Antagonist 80 % of Patients 60 40 20 0 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2017 Analysis is limited to patients who were alive at the time of the discharge. JHLT. 2017 Oct; 36(10): 1037-1079

  27. Adult Heart-Lung Transplants Induction Immunosuppression (Transplants: January 2004 December 2015) 100 Any induction Polyclonal ALG/ATG IL-2R Antagonist 90 80 70 % of Patients 60 50 40 30 20 10 0 2017 Analysis is limited to patients who were alive at the time of the discharge. JHLT. 2017 Oct; 36(10): 1037-1079

  28. Adult Heart-Lung Transplants Maintenance Immunosuppression at Time of 1 Year Follow-up (Follow-ups: January 2004 June 2016) 100 N = 241 80 % of Patients 60 40 20 0 Cyclosporine Tacrolimus Sirolimus/ Everolimus MMF/MPA Azathioprine Prednisone 2017 Analysis is limited to patients who were alive at the time of the follow-up. JHLT. 2017 Oct; 36(10): 1037-1079

  29. Adult Heart-Lung Transplants Maintenance Immunosuppression Drug Combinations at Time of 1 Year Follow-up (Follow-ups: January 2004 June 2016) 100% Other Sirolimus/Everolimus + Calcineurin Inhibitor + Cell Cycle Inhibitor 80% Sirolimus/Everolimus + Calcineurin Inhibitor 60% Tacrolimus Tacrolimus + MMF/MPA 40% Tacrolimus + AZA Cyclosporine + MMF/MPA 20% Cyclosporine + AZA 0% Year 1 (N=241) 2017 Analysis is limited to patients who were alive at the time of the follow-up. JHLT. 2017 Oct; 36(10): 1037-1079

  30. Post Transplant Morbidities 2017 JHLT. 2017 Oct; 36(10): 1037-1079

  31. Adult Heart-Lung Transplants Cumulative Post Transplant Morbidity Rates in Survivors within 1 and 5 Years (Transplants: January 1994 June 2015) Total number with known response Total number with known response Within 1 Year Within 5 Years Outcome Renal Dysfunction 20.0% (N=500) 43.0% (N=237) Abnormal Creatinine 2.5 mg/dl Creatinine > 2.5 mg/dl Chronic Dialysis Renal Transplant 12.0% 3.4% 4.4% 0.2% 27.8% 11.0% 3.0% 1.3% Diabetes 17.7% (N=521) 28.4% (N=264) Cardiac Allograft Vasculopathy 2.9% (N=408) 6.8% (N=132) Bronchiolitis Obliterans Syndrome 7.5% (N=478) 31.5% (N=219) 2017 JHLT. 2017 Oct; 36(10): 1037-1079

  32. Adult Heart-Lung Transplants Freedom from Cardiac Allograft Vasculopathy and Bronchiolitis Obliterans Syndrome (Transplants: January 1994 June 2015) 100 Freedom from CAV and BOS (%) 75 50 25 Cardiac Allograft Vasculopathy-free survival (N=409) Bronchiolitis Obliterans Syndrome-free survival (N=481) 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Years 2017 JHLT. 2017 Oct; 36(10): 1037-1079

  33. Adult Heart-Lung Transplants Freedom from Severe Renal Dysfunction (Transplants: January 1994 June 2015) 100 N=497 Freedom from Severe Renal 75 Dysfunction (%) 50 25 *Severe renal dysfunction = Creatinine > 2.5 mg/dl (221 mol/L), dialysis or renal transplant 0 0 1 2 3 4 5 6 7 Years 8 9 10 11 12 13 14 15 2017 JHLT. 2017 Oct; 36(10): 1037-1079

  34. Adult Heart-Lung Transplants Cumulative Post Transplant Malignancy Rates in Survivors (Transplants: January 1994 June 2015) 1-Year Survivors 5-Year Survivors 10-Year Survivors Malignancy/Type 473 (94%) 236 (89.1%) 104 (83.9%) No Malignancy 30 (6.0%) 29 (10.9%) 20 (16.1%) Malignancy (all types combined) 3 14 13 Malignancy Type* Skin 20 8 3 Lymphoma 5 6 5 Other 2 1 0 Type Not Reported * Recipients may have experienced more than one type of malignancy so the sum of individual malignancy types may be greater than the total number with malignancy. 2017 JHLT. 2017 Oct; 36(10): 1037-1079

  35. Adult Heart-Lung Transplants Freedom from Malignancy (Transplants: January 1994 - June 2015) 100 Freedom from Malignancy (%) 90 80 70 All malignancy Lymphoma Skin Other 60 50 0 1 2 3 4 5 6 7 8 9 10 11 12 Years 2017 JHLT. 2017 Oct; 36(10): 1037-1079

  36. Adult-Heart Lung Transplants Cause of Death (Deaths: January 1992 June 2016) CAUSE OF DEATH 0-30 Days (N=472) 31 Days - 1 Year (N=360) >1 Year - 3 Years (N=294) >3 Years - 5 Years (N=175) >5 Years (N=535) OB/BOS 0 14 (3.9%) 69 (23.5%) 38 (21.7%) 110 (20.6%) ACUTE REJECTION 7 (1.5%) 6 (1.7%) 5 (1.7%) 1 (0.6%) 3 (0.6%) LYMPHOMA 0 7 (1.9%) 12 (4.1%) 8 (4.6%) 11 (2.1%) MALIGNANCY, OTHER 1 (0.2%) 8 (2.2%) 13 (4.4%) 7 (4.0%) 43 (8.0%) CMV 0 2 (0.6%) 2 (0.7%) 1 (0.6%) 1 (0.2%) INFECTION, NON-CMV 80 (16.9%) 126 (35.0%) 84 (28.6%) 45 (25.7%) 115 (21.5%) GRAFT FAILURE 127 (26.9%) 76 (21.1%) 44 (15.0%) 32 (18.3%) 78 (14.6%) CARDIOVASCULAR 39 (8.3%) 15 (4.2%) 22 (7.5%) 18 (10.3%) 53 (9.9%) TECHNICAL 110 (23.3%) 12 (3.3%) 3 (1.0%) 3 (1.7%) 7 (1.3%) MULTIPLE ORGAN FAILURE 51 (10.8%) 54 (15.0%) 15 (5.1%) 7 (4.0%) 36 (6.7%) OTHER 57 (12.1%) 40 (11.1%) 2017 25 (8.5%) 15 (8.6%) 78 (14.6%) JHLT. 2017 Oct; 36(10): 1037-1079

  37. Adult Heart-Lung Transplants Cause of Death by Transplant Type (Deaths: January 1992 June 2016) Transplant Type Cause of Death >1 Year - 3 Years >3 Years - 5 Years 0-30 Days 31 Days - 1 Year >5 Years OB/BOS 0 14 (4.0%) 69 (23.8%) 38 (22.0%) 107 (20.2%) Malignancy 1 (0.2%) 15 (4.3%) 24 (8.3%) 15 (8.7%) 54 (10.2%) Infection 78 (17.1%) 123 (34.9%) 84 (29.0%) 46 (26.6%) 115 (21.7%) Primary Graft Failure 123 (26.9%) 76 (21.6%) 43 (14.8%) 32 (18.5%) 78 (14.7%) Cardiovascular 39 (8.5%) 13 (3.7%) 22 (7.6%) 18 (10.4%) 52 (9.8%) Technical 108 (23.6%) 12 (3.4%) 3 (1.0%) 3 (1.7%) 7 (1.3%) All known causes 457 352 290 173 530 OB/BOS 0 0 0 0 3 (60.0%) Malignancy 0 0 0 0 0 Infection 1 (14.3%) 2 (50.0%) 1 (100.0%) 0 1 (20.0%) Retransplant Graft Failure 3 (42.9%) 0 0 0 0 Cardiovascular 0 2 (50.0%) 0 0 1 (20.0%) Technical 1 (14.3%) 0 0 0 0 All known causes 7 2017 4 1 2 5 Acute rejection and other causes of death are not shown on the slide. JHLT. 2017 Oct; 36(10): 1037-1079

  38. Adult Heart-Lung Transplants Relative Incidence of Leading Causes of Death (Deaths: January 1992 June 2014) OB/BOS Graft Failure Infection (non-CMV) Cardiovascular Technical 40 30 % of Deaths 20 10 0 0-30 Days (N=472) 31 Days - 1 Year (N=360) >1-3 Years (N=294) >3-5 Years (N=175) >5 Years (N=535) 2017 JHLT. 2017 Oct; 36(10): 1037-1079

  39. Multivariable Analysis 2017 JHLT. 2017 Oct; 36(10): 1037-1079

  40. Adult Heart-Lung Transplants (1998-6/2015) Statistically Significant Risk Factors For 1 Year Mortality with 95% Confidence Limits 2017 (N = 1,609) JHLT. 2017 Oct; 36(10): 1037-1079

  41. Adult Heart-Lung Transplants (1998-6/2015) Statistically Significant Risk Factors For 1 Year Mortality Continuous Factors (see figures) Center Lung and Heart-Lung Volume: Previous Txs Within 1 Yr. 2017 JHLT. 2017 Oct; 36(10): 1037-1079

  42. Adult Heart-Lung Transplants (1998-6/2015) Statistically Significant Risk Factors For 1 Year Mortality with 95% Confidence Limits Center Lung and Heart-Lung Volume: Previous Txs Within 1 Yr. 2.5 Hazard Ratio for 1 Year Mortality p = 0.0068 2.0 1.5 1.0 0.5 0.0 5 10 15 Center Lung and Heart-Lung Volume: Previous Txs Within 1 Yr. 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 2017 (N = 1,609) JHLT. 2017 Oct; 36(10): 1037-1079

  43. Focus Theme 2017 JHLT. 2017 Oct; 36(10): 1037-1079

  44. Adult Heart-Lung Transplants Ischemic Time Distribution by Diagnosis (Transplants: January 2004 June 2016) 0-<2 hours 2-<4 hours 4-<6 hours 6+ hours 100% 80% % of Transplants 60% 40% 20% 0% CF IIP IPAH PH-not IPAH Other 2017 JHLT. 2017 Oct; 36(10): 1037-1079

  45. Adult Heart-Lung Transplants Ischemic Time Distribution by Recipient Age (Transplants: January 2004 June 2016) 0-<2 hours 2-<4 hours 4-<6 hours 6+ hours 100% 80% % of Transplants 60% 40% 20% 0% 18-34 35-49 Recipient Age (Years) 2017 50-59 60+ JHLT. 2017 Oct; 36(10): 1037-1079

  46. Adult Heart-Lung Transplants Ischemic Time Distribution by Recipient Ventilator Support (Transplants: January 2004 June 2016) at Transplant 0-<2 hours 2-<4 hours 4-<6 hours 6+ hours 100% 80% % of Transplants 60% 40% 20% 0% No ventilator support Ventilator support 2017 JHLT. 2017 Oct; 36(10): 1037-1079

  47. Adult Heart-Lung Transplants Ischemic Time Distribution by Donor Age (Transplants: January 2004 June 2016) 0-<2 hours 2-<4 hours 4-<6 hours 6+ hours 100% 80% % of Transplants 60% 40% 20% 0% 12-17 18-34 35-49 50-59 Donor Age (Years) 2017 JHLT. 2017 Oct; 36(10): 1037-1079

  48. Adult Heart-Lung Transplants Ischemic Time Distribution by Donor Cause of Death (Transplants: January 2004 June 2016) 0-<2 hours 2-<4 hours 4-<6 hours 6+ hours 100% 80% % of Transplants 60% 40% 20% 0% Anoxia Cerebrovascular/ Stroke 2017 Head Trauma Other JHLT. 2017 Oct; 36(10): 1037-1079

  49. Adult Heart-Lung Transplants Ischemic Time Distribution by Year of Transplant 0-<2 hours 2-<4 hours 4-<6 hours 6+ hours Median Ischemic Time Median ischemic time (blue line; hours) 100% 6.0 90% 5.0 80% % of transplants 70% 4.0 60% 50% 3.0 40% 2.0 30% 20% 1.0 10% 0% 0.0 2017 JHLT. 2017 Oct; 36(10): 1037-1079

  50. Adult Heart-Lung Transplants Ischemic Time Distribution by Location (Transplants: January 2004 June 2016) 0-<2 hours 2-<4 hours 4-<6 hours 6+ hours 100% 80% % of Transplants 60% 40% 20% 0% Europe North America Others 2017 JHLT. 2017 Oct; 36(10): 1037-1079

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