Prior Sternotomy Does Not Adversely Impact Survival or Allograft Function after Heart Transplantation

Abstract

Purpose Orthotopic heart transplantation (OHT) remains the gold standard for end-stage heart failure. The number of patients who have had at least one prior sternotomy while awaiting transplantation is increasing. Redo sternotomy before OHT may increase operative complexity thus affecting the outcomes. Methods We retrospectively analyzed patients who underwent OHT at our institution, during a 17-year period. All patients who underwent prior sternotomy were compared with those undergoing OHT with a virgin chest. Patients who underwent left ventricular assist device (LVAD) support as bridge to transplantation were excluded, in the study. Preoperative, intraoperative, and postoperative variables were analyzed. Short- and long-term outcomes/survival were studied. Primary and secondary graft failure after OHT were weighted. To account for bias in selection of patients a propensity score (PS) model was constructed and adopted. Kaplan-Meier survival estimates of overall and adverse events-free survival were compared using a paired analysis. Results A total of 461 adult patients underwent OHT, between 2000 and 2017. Unmatched population: No prior sternotomy OHT patients (n=343) vs. prior sternotomy OHT patients (n=118). PS matched population: No prior sternotomy OHT patients (n=118) vs. prior sternotomy OHT patients (n=118). Overall 30-day mortality was slightly lower in the prior sternotomy OHT group, but not significantly (13.3% vs 7.7%, p=0.14). The two groups showed similar perioperative outcomes. Long-term survival (5-year and 10-year) was similar in the two groups (80.9% vs. 75.7% and 72.5 vs. 67.4 %; log-rank, p=0.41). The subgroups analysis revealed prior valvular surgery associated with a coronary artery bypass grafting (CABG) procedure as risk factor for 30-day mortality (OR 6.2; p=0.01). Conclusion Redo sternotomy before OHT may increase operative complexity but not affecting the outcomes in terms of survival or allograft function.Type of prior surgical procedure should be properly weighted to preserve the outcomes at the time of OHT.