Infectious complications in extended criteria heart transplantation.

Background: We have previously shown that extended criteria heart transplant recipient mortality is higher than standard list mortality, but this is not associated with an increased incidence of either primary graft dysfunction or acute rejection. We hypothesized that other adverse outcomes, principally determined by recipient characteristics, occur at a higher rate in extended criteria recipients.

Methods: A retrospective review of adult heart transplant recipients was conducted at Duke University Medical Center between January 2000 and July 2007. Infectious complications considered risk factors for recipient mortality were identified. In addition, the incidence of these complications was compared between standard and alternate list recipients.

Results: Infectious complications, including pneumonia, bacteremia and sepsis, were significant predictors of overall mortality (pneumonia hazard ratio 4.2 [95% CI 2.5 to 7.0], bacteremia hazard ratio 3.0 [95% CI 1.9 to 4.9], sepsis hazard ratio 6.0 [95% CI 3.6 to 10.2]). In addition, pneumonia occurred at a significantly higher rate in extended criteria (EC) than in standard list (SL) patients (27% vs 13%, p = 0.005), and bacteremia and sepsis demonstrated a trend toward higher occurrence in EC patients (36% vs 25%, p = 0.076, and 15% vs 8%, p = 0.114, respectively). In contrast, severe acute cellular rejection (ISHLT Grade >/=3A) was not a predictor of mortality, and had a similar incidence in both groups. Finally, although overall survival among patients in the SL group was not influenced by the occurrence of a major infectious complication, survival in the extended criteria group was significantly impacted by major infectious complications (p < 0.001).

Conclusions: Infectious complications may account for decreased survival in extended criteria heart transplant recipients.