Is Third-time Heart Re-Transplantation Justifiable?

Since repeat heart transplantation traditionally carries higher risk than primary engraftment, we tested the hypothesis that third-time cardiac allograft transplantation is associated with prohibitive mortality and morbidity. The cohort of all third time cardiac retransplants performed at our institution (N=3) and reported to UNOS from 1987 to 2002 (N = 10) was reviewed. The primary endpoints were early and late mortality. Extending the study frame through 2003 captures a total of 5 and 15 third-time heart transplant recipients in UCLA and UNOS databases respectively. Of the fifteen patients undergoing third-time retransplants, pre-operatively 1 was VAD dependent, 4 were on IV inotropes, and 2 had creatinine levels greater than 2.5. Additionally, 4 were male recipients of female donor hearts and the mean donor ischemic time was 2.6 hours. One patient was diagnosed with acute allograft rejection, thirteen with CAV/chronic rejection, and one with primary graft failure. At our institution, five patients underwent a third heart transplant. There was no early or hospital mortality. One patient died late from TCAD and another following a fourth allograft. The mortality rate for third-time heart allograft recipients is acceptable. These results are influenced by small sample size, younger age, case selection, and operations at select, high-volume institutions with significant experience.