Background:Outcomes after heart transplantation for anthracycline-induced cardiomyopathy (AICM) remain incompletely characterized, particularly compared with idiopathic dilated cardiomyopathy (DCM) and ischemic cardiomyopathy (ICM). Methods:We analyzed adult first-time isolated heart transplant recipients in the Organ Procurement and Transplantation Network/United Network for Organ Sharing registry from January 1, 2000, to September 25, 2025. Recipients were grouped as AICM, idiopathic DCM, or ICM by registry diagnosis. The primary outcome was all-cause post-transplant mortality. Secondary outcomes included graft failure, post-transplant dialysis, stroke, pacemaker implantation, treated rejection, and length of stay. Results:Compared with idiopathic DCM, AICM was not associated with higher adjusted mortality (HR 1.11, 95% CI 0.98-1.25; p=0.111) or graft failure (HR 1.09, 95% CI 0.96-1.23; p=0.185) but was associated with post-transplant dialysis (OR 1.31, 95% CI 1.03-1.67; p=0.030) and longer index hospitalization (IRR 1.12, 95% CI 1.06-1.18; p<0.001). AICM was also associated with higher malignancy-related mortality compared with idiopathic DCM (sHR 2.27, 95% CI 1.66-3.09; p<0.001) and ICM (sHR 1.70, 95% CI 1.24-2.33; p<0.001). Conclusions:Among selected adult heart transplant recipients, anthracycline-induced cardiomyopathy was not associated with worse post-transplant survival or graft failure compared with idiopathic DCM. However, AICM recipients had higher adjusted odds of post-transplant dialysis, longer index hospitalization, and a greater burden of malignancy-related death, highlighting the need for individualized oncologic and renal-risk assessment in transplant candidates with prior anthracycline exposure.
Background Despite major advances in targeted therapies, lung transplantation remains a key option for selected patients with end-stage pulmonary arterial hypertension (PAH) but is associated with substantial clinical and organizational challenges. Our aim was to describe the impact of changes in advanced PAH management and referral strategies on the profile of transplanted patients and outcomes. Methods All patients with PAH (except congenital heart disease), who underwent lung or heart–lung transplantation between 2008 and 2023 were retrospectively studied in France. Data were obtained from the National PAH and Transplant Registries. Patient characteristics, transplant strategies, and outcomes were compared between 2008–2015 (period 1) and 2016–2023 (period 2). Results Overall, 241 PAH patients underwent transplantation. The proportion of patients aged ≥50 years increased from 30% to 44% (p=0.04). Time from diagnosis to transplantation tended to increase (39 vs. 46 months, p=0.2). Pre-operative extracorporeal membrane oxygenation (ECMO) as a bridge to transplantation increased from 6% to 14% (p=0.05), while post-operative ECMO use remained stable (35% vs. 36%). Three-month post-transplant survival was 85% (95% CI 78–92%) and 91% (95% CI 86–96%) in periods 1 and 2, respectively. In the PAH population aged <65 years, the ratio of deaths without transplantation to transplantations performed exceeded 5:1, with marked heterogeneity across aetiologies. Conclusion Advances in severe PAH management have enabled transplantation in older and more intensively treated patients without compromising short-term outcomes. However, major disparities in access to transplantation persist across PAH aetiologies, underscoring the persistent challenges in advanced PAH management.
Background Inactive waitlist status is common in lung transplantation, but the extent to which distinct inactivity phenotypes identify candidates at risk of failing to survive to transplantation is uncertain. Methods We analyzed adult U.S. lung transplant candidates listed from January 1, 2005, through March 31, 2026, using OPTN STAR files. Inactivity was characterized by cumulative inactive days, first inactivation reason, and cycling. Logistic models evaluated death or removal for being too sick; sequential severity adjustment, multiple imputation, 90- and 180-day landmark competing-risk analyses, and exclusion of initially inactive candidates assessed robustness. Results Among 56,268 candidates, 16,301 (29.0%) experienced inactivity. Compared with candidate choice, temporary too-sick inactivation had the strongest association with death or too-sick removal in the original model (OR, 5.72; 95% CI, 4.88-6.71) and after full severity adjustment with multiple imputation (OR, 4.40; 95% CI, 3.74-5.17). At the 90-day landmark, adjusted subdistribution hazards increased across nonzero burden groups (sHRs, 1.25-1.45). At 180 days, burden greater than 10 days remained associated with subsequent risk (sHRs, 1.21-1.45), whereas greater than 0 to 10 days was not. Excluding 1,354 candidates initially listed inactive did not materially change the too-sick estimate (OR, 5.83; 95% CI, 4.94-6.88). Conclusions Inactive status represents heterogeneous clinical and administrative phenotypes. Temporary too-sick inactivation remained strongly associated with failure to survive to transplantation after extensive severity adjustment, whereas landmark analyses separately demonstrated that sustained early inactive burden was associated with subsequent risk.
Background Non-invasive surveillance of acute cellular rejection (ACR) has become a primary focus in heart transplantation (HTx), aiming to reduce the frequency of invasive endomyocardial biopsies (EMB). While Cardiac Magnetic Resonance (CMR) with T1 mapping has shown promise as a diagnostic tool, its application during the early post-transplant phase remains a significant knowledge gap, as perioperative tissue injury can confound imaging interpretation. Objective To evaluate the accuracy of cardiac T1 mapping for acute cellular rejection (ACR) in heart transplant recipients within the first 60 days post-transplantation, using endomyocardial biopsy (EMB) as the reference standard. Methods This prospective single-center study included adult HTx recipients within 60 days post-transplant. All patients underwent CMR with native T1 mapping and extracellular volume (ECV) quantification. EMB served as the gold standard, classifying patients into non-significant (<2R) and significant (≥2R) rejection groups. Results Forty-five recipients were included; 14 (31.1%) presented with cellular rejection ≥2R. Baseline characteristics such as recipient mean age (50.1 vs. 49.6 years, p = 0.79) and the interval from HTx to CMR (32 vs. 31.4 days, p = 0.86) were comparable between groups. Native T1 (1048 ± 46.2 vs. 1006.6 ± 60.6 ms, p = 0.028) and ECV (36.8 ± 5.3% vs. 33.2 ± 5.5%, p = 0.043) were significantly elevated in the ≥2R group. Native T1 demonstrated an AUC of 0.700 for diagnosing rejection ≥2R (cutoff: 1036.5 ms; sensitivity 64.3%, specificity 74.2%, PPV 52.9%, NPV 82.1%), whereas ECV yielded an AUC of 0.726 (cutoff: 37.9%; sensitivity 57.1%, specificity 90.3%, PPV 72.7%, NPV 82.4%). Multivariate analysis identified indexed RV end-diastolic volume and the presence of late gadolinium enhancement (LGE) as independent predictors of rejection. However, a multiparametric approach combining native T1 <1037 ms, ECV <38%, and absence of LGE yielded a NPV of 100% within this small subgroup. Conclusion The diagnostic accuracy of standalone T1 mapping for identifying ACR was modest in this early post-HTx period. However, native T1 and ECV were significantly higher in the rejection group, and their integration into a multiparametric approach, including LGE, demonstrated a high NPV in this cohort. These findings highlight CMR’s potential for monitoring myocardial changes even in the early post-transplant stage.
Background Acute kidney injury (AKI) is common after lung transplantation (LUTX), with standard diagnostic criteria having limited early accuracy. We evaluated the AKI and postoperative outcomes risk-stratification performance of subclinical AKI and creatinine-independent kidney-injury phenotypes. Methods In this prospective single-center cohort including bilateral LUTX recipients, we measured urinary Tissue Inhibitor of Metalloproteinases-2 and Insulin-Like Growth Factor-Binding Protein 7 (u[TIMP-2]*[IGFBP-7]) and plasma Heart-Type Fatty Acid-Binding Protein (H-FABP), midkine, Soluble Tumor Necrosis Factor Receptor 1 (sTNFR1), and sTNFR2 at 6 and 36 hours after reperfusion, using point-of-care devices. AKI was defined by KDIGO criteria. Subclinical AKI was defined as u[TIMP-2]*[IGFBP-7]>0.3 without AKI criteria. Creatinine-independent phenotypes were identified with outcome-agnostic Latent Profile Analysis (LPA). Results Among 84 included patients, 30 (36%) developed AKI. u[TIMP-2]*[IGFBP-7] had modest AKI discrimination, with best AUROC 0.63 (95%CI 0.58-0.70) at 36 hours. Twenty-five patients had subclinical AKI, which had outcomes similar to those of patients without AKI. At 36 hours, plasma H-FABP, sTNFR1, and sTNFR2 were higher in patients with AKI. LPA identified 3 classes: low-risk (30%), intermediate-risk (51%), and high-risk (19%), with increasing rates of AKI (16%, 42%, 72%; p=0.006) and primary graft dysfunction grade 3 at 72 hours (4%, 13%, 35%; p=0.045). Compared with the low-risk class, the high-risk class had fewer organ support-free, ICU-free, and hospital-free days, and the lowest rejection-free survival. Conclusions After LUTX, u[TIMP-2]*[IGFBP-7] had limited risk-stratification performance, and subclinical AKI was not associated with a distinct clinical course. In contrast, plasma biomarker-derived risk phenotypes were associated with AKI severity and postoperative trajectory.
Driveline infections are a leading cause of morbidity in patients with a home left ventricular assist device (LVAD). We report a case of culture-negative, recurrent driveline exit-site inflammation with a triphasic clinical course (91 days, 14 photographs) in VAD018, managed entirely as an outpatient—without antibiotic therapy—through VAD coordinator-led review of weekly self-photographed personal health record (PHR) submissions via the Minatowa platform. A Bayesian deterioration algorithm, applied retrospectively and incorporating photographic wound scores as a likelihood ratio component, identified all three clinical peaks (P[deterioration] >0.80) at timepoints corresponding to coordinator-initiated intensification of wound care. For context, VAD034, a patient without PHR monitoring, experienced a 26-day hospitalization for driveline exit-site inflammation of comparable peak severity, also culture-negative, ultimately managed with incision and irrigation. These findings are hypothesis-generating and motivate prospective evaluation of coordinator-led, PHR-based photographic surveillance, planned as the Local LVAD Home Management (LHM) Trial.
Cardiac allograft vasculopathy remains a major cause of late graft dysfunction and mortality after heart transplantation. Percutaneous coronary intervention can treat focal epicardial disease, but its role is complicated by diffuse epicardial involvement, microvascular dysfunction, donor-transmitted or conventional atherosclerosis, alloimmune injury, and limited transplant-specific interventional evidence. This narrative review examines cardiac allograft vasculopathy from the perspective of the interventional cardiologist, focusing on lesion selection, procedural optimisation, and longitudinal management after intervention.Longitudinal graft assessment contextualises whether a stenosis reflects donor-derived disease, acquired atherosclerosis, progressive alloimmune vasculopathy, or overlapping processes, while donor-specific antibodies and rejection history provide complementary information regarding alloimmune risk. Coronary angiography remains central when revascularisation is contemplated, with intravascular imaging defining vessel dimensions, disease distribution, and procedural strategy. Coronary computed tomography angiography can exclude significant epicardial disease in appropriately selected recipients, whereas functional imaging and invasive coronary physiology characterise graft-wide haemodynamic and microvascular disease. However, no single anatomical, physiological, or immunological threshold has been prospectively validated for percutaneous coronary intervention.Drug-eluting stents are generally favoured for suitable focal lesions based on lower restenosis rates, although graft-level clinical benefit remains unproven. Post-intervention management should distinguish target-lesion failure from graft-wide disease progression and incorporate continued surveillance and transplant-directed disease modification. By distinguishing guideline-supported and transplant-specific evidence from native coronary extrapolation, this review proposes an evidence-informed interpretive framework in which percutaneous coronary intervention treats a mechanically correctable component of graft vascular disease rather than allograft vasculopathy itself.
Heart failure is a global health challenge with significant impacts on quality of life and healthcare systems. Heart transplantation remains the gold standard for select patients with end-stage heart failure, yet access in Latin America is limited by economic constraints, systemic barriers, and inequities in infrastructure. Despite contributing less than 7% of global Heart transplant procedures, LATAM has made important strides, with countries like Argentina demonstrating success in increasing donor rates through presumed consent legislation. However, disparities in donor availability, centralized heart transplant centers, and survival outcomes persist. This article reviews LATAM's historical contributions, current state, and challenges in heart transplant, identifying critical barriers such as the absence of unified transplant registries, limited access to advanced technologies like LVADs and ECMO, and a shortage of specialized training programs. Cultural attitudes and misconceptions surrounding organ donation further compound these issues. Solutions discussed include establishing a regional transplant registry to improve data transparency, leveraging regional collaboration to expand donor pools, and implementing public awareness campaigns to address cultural barriers. With concerted efforts in education, legislation, cost reduction, and technology integration, LATAM has the potential to significantly improve heart transplant access and outcomes. This transformation would save countless lives and position the region as a key contributor to global advancements in heart transplant.
Background:Cardiac magnetic resonance (CMR) enables comprehensive assessment of right ventricular (RV) function and ventricular-vascular interaction in pulmonary arterial hypertension (PAH). This exploratory pilot study compared echocardiographic and CMR-derived surrogate indices of RV-pulmonary arterial (RV-PA) coupling and examined indexed pulmonary artery compliance (PAc) in adolescents and young adults with PAH. Methods:Twenty adolescents and young adults with Group 1 PAH underwent transthoracic echocardiography, CMR, and cardiac catheterization within 7 days. Echocardiographic TAPSE/systolic pulmonary artery pressure (sPAP) and CMR RV stroke volume/end-systolic volume were analyzed as noninvasive surrogates of RV-PA coupling; pressure-volume loop-derived end-systolic elastance/arterial elastance was not measured. Indexed PAc and pulmonary vascular resistance index (PVRi) were derived from catheterization and CMR data. Associations with WHO functional class, N-terminal pro-B-type natriuretic peptide (NT-proBNP), and 6-minute walk distance (6MWD) were explored. Results:Echocardiographic TAPSE/sPAP showed limited associations with clinical severity measures. CMR-derived RV indices showed stronger exploratory associations with NT-proBNP and 6MWD. In the prespecified multivariable model of the exercise endpoint, indexed PAc had the largest standardized coefficient (β = -0.78; 95% CI, -1.48 to -0.09; p = 0.031); PVRi and the imaging surrogates were not statistically significant. Estimates were imprecise because of the small sample. Conclusions:In this small, hypothesis-generating cohort, CMR-derived RV-PA coupling and indexed PAc provided complementary physiologic information beyond the echocardiographic surrogate. These observations require validation against pressure-volume loop-derived coupling and prospective clinical outcomes.
Introduction:Recent policy reforms, including the 2017 implementation of a 250 nautical mile (nm) donor sharing radius and the 2023 introduction of the Composite Allocation Score (CAS), have substantially changed lung allocation in the United States. The effects of these policy reforms on the structural organization of lung transplant programs and associated outcomes remain unclear. Methods:Adult lung transplant recipients in the OPTN/UNOS STAR registry between January 1, 2015 and December 31, 2025 were identified. Transplants performed during the COVID-19 pandemic period (March 2020 to June 2021) were excluded. Allocation eras were defined as lung allocation score-donor service area (LAS-DSA) (January 2015 to November 2017), LAS-250 nm (November 2017 to March 2023), and CAS (March 2023 to December 2025). National concentration of transplant activity across centers was assessed using the Herfindahl-Hirschman Index (HHI) and Gini coefficient. Center volume dynamics were evaluated, and 1-year survival was assessed using Kaplan-Meier and multivariable Cox regression analysis. Results:Among 25,460 lung transplant recipients, national transplant activity became progressively less concentrated across eras. HHI declined from 0.0273 in the LAS-DSA era to 0.0237 in the CAS era (p<0.001), while the Gini coefficient decreased from 0.436 to 0.384 (p<0.001). Median annualized center transplant volume increased from 23.8/year in the LAS-DSA era to 39.8/year in the CAS era (p=0.051). Unadjusted 1-year survival improved across eras (89.2% LAS-DSA, 89.3% LAS-250 nm, 91.7% CAS; log-rank p<0.001). In adjusted analysis, the CAS era was associated with lower mortality than the LAS-250 nm era (aHR 0.74, 95% CI 0.65-0.83; p<0.001). Conclusions:Lung allocation reform significantly redistributed transplant activity across U.S. centers while improving survival.
Background:Pulmonary hypertension (PH) has been described in chronic lung allograft dysfunction (CLAD), but its prevalence and prognostic significance in patients listed for lung retransplantation remain uncertain. We sought to determine the national prevalence of PH among adults listed for lung retransplantation for CLAD and to evaluate its association with waitlist and post-transplant outcomes. Methods:We analyzed SRTR data from May 2005 through September 2025 for adults listed for lung retransplantation for CLAD with right heart catheterization data at listing. PH was defined as mean pulmonary artery pressure (mPAP) greater than 20 mmHg. The primary outcome was waitlist mortality, analyzed using Fine-Gray competing-risk regression with transplantation treated as a competing event. Secondary outcomes included 30-day and 1-year post-transplant mortality. Results:Among 1440 eligible patients, 58% met hemodynamic criteria for PH at listing. PH prevalence did not differ between bronchiolitis obliterans syndrome (BOS) and restrictive allograft syndrome (RAS). In adjusted competing-risk models, PH was independently associated with increased waitlist mortality (Subdistribution hazard ratio 1.37, 95% CI 1.08-1.74). When mPAP was modeled continuously, higher pulmonary pressures were associated with progressively greater risk of waitlist mortality without a threshold effect. Among patients with complete hemodynamic data, pre-capillary PH was numerically more common in RAS than BOS (31.5% vs 28.2%), while isolated post-capillary PH (10.5% vs 9.9%) and combined pre/post-capillary PH (5.9% vs 7.0%) were similar. PH was not associated with 30-day or 1-year post-transplant mortality. Patients with PH were more likely to remain intubated at 72 hours after retransplantation, while other early postoperative outcomes were similar. Conclusions:PH is common in adults listed for lung retransplantation for CLAD and is independently associated with increased waitlist mortality, but not early post-transplant mortality.
Background Infection complicates temporary mechanical circulatory support (tMCS) in cardiogenic shock (CS), but the contributions of device, severity, and timing remain unclear. Methods Adults with CS supported by Impella, venoarterial extracorporeal membrane oxygenation (VA-ECMO), or both (ECPELLA) at a quaternary center (2021-2025) were studied retrospectively. Infection required clinician diagnosis, positive culture, and ≥5 days of targeted therapy. Cause-specific Cox and Fine-Gray competing-risks models assessed infection and a separate Cox model assessed 60-day mortality with infection as a time-varying covariate. Results Among 297 patients, 111 (37.4%) developed a post-tMCS infection. Most first infections (75.7%) occurred within 14 days, with week-1 incidence over twice the average. Infected patients had longer hospital stays (35 vs 19 days, P<0.001) and were less often discharged home (13.5% vs 31.2%, P<0.001) but had similar in-hospital mortality (37.8% vs 37.6%, P=0.972). Relative to Impella use alone, VA-ECMO use alone (cause-specific HR 2.70, 95% CI 1.63-4.48, P<0.001) and ECPELLA use (HR 1.79, 95% CI 1.10-2.93, P=0.020) were independently associated with infection (concordant on Fine-Gray analysis). Older age (HR 1.03/year, 95% CI 1.02-1.05, P<0.001) and higher lactate at tMCS placement (HR 1.08 per mmol/L, 1.04-1.12, P<0.001) were independently associated with 60-day mortality, while infection was not. Conclusions Infection affected more than one-third of CS-tMCS patients, with peak risk in the first week. VA-ECMO support carried higher infection risk. 60-day mortality tracked older age and lactate at tMCS placement, but not device type. Infection was not associated with increased mortality but was associated with longer hospitalization and worse discharge disposition.
Background Lung transplant recipients (LTRs) are at increased risk of genitourinary cancers (GUCs) but do not undergo routine surveillance. This study describes the cumulative incidence and clinical outcomes of GUC among LTRs. Methods This single-center, retrospective cohort study included all adult LTRs transplanted between 2010 and 2020 with histologically confirmed posttransplant bladder or ureteral cancer. The primary outcome was the cumulative incidence (CI) of GUC. We estimated the subdistribution hazard ratio (sHR) for GUC using a competing risks proportional hazards model. Secondary outcomes, including post-diagnosis survival, were analyzed using Kaplan-Meier curves and the log-rank test for comparisons. Statistical significance was set at p<0.05. We also described patient and disease characteristics and treatments. Results Among 835 LTRs, 15 developed posttransplant GUC (13 bladder and 2 ureteral); 11 were diagnosed >5 years post-LT. The CI was 1.8%. The cohort was predominantly male (73.3%) with a median age of 72.5 years (IQR 68–77.8) and substantial tobacco exposure (≥20 pack-years: 93.3%). GUC was diagnosed at a median of 75 months (IQR 52.1-103.6) posttransplant. Mortality was high (73.3% deceased at follow-up) with a median survival of 196 days post-diagnosis. Obstructive lung disease (OLD) was associated with a markedly higher subdistribution hazard of posttransplant GUC (sHR: 4.99 [p=0.0058]), which persisted after multivariable adjustment for age at transplant, sex, and smoking history (adjusted sHR: 5.05 [p=0.007]). Conclusions GUCs were a rare but clinically important late complications after LT, frequently presented with aggressive features, and were associated with poor survival. The association with OLD should be interpreted cautiously given the small number of events and potential confounding by cumulative tobacco exposure. These findings support further study of risk-adapted surveillance strategies in higher-risk LTRs.
Background Soluble ST2 (sST2) is a decoy receptor for interleukin-33 and a prognostic biomarker in heart failure, but its utility in precapillary pulmonary hypertension (PH) is not well established. Therefore, we aimed to evaluate the prognostic value of sST2 in patients with pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) at diagnosis and follow-up. Materials and methods In this prospective observational cohort study, we measured plasma sST2 by sandwich enzyme-linked immunosorbent assay in samples taken at diagnostic right heart catheterization from 202 treatment naïve Norwegian patients with precapillary PH (n = 115 with PAH, n = 87 with CTEPH). In an external validation cohort, we included 185 treatment naïve Swedish patients with precapillary PH (n = 121 with PAH, n= 64 with CTEPH). In a subset of patients, we measured sST2 levels at follow-up in the Norwegian discovery cohort (n=63) and the Swedish validation cohort (n=121). Results On univariable Cox regression, log sST2 was firmly associated with transplant-free survival in the Norwegian discovery cohort (HR 1.92, P = 0.005) and in the Swedish validation cohort (HR 2.64, P <.001). When adjusting for age and NT-proBNP, sST2 levels were no longer significantly associated with transplant-free survival in the discovery cohort, while remaining independently associated with the outcome in the validation cohort. The change in sST2 from baseline to follow-up was not associated with transplant-free survival in either cohort. Conclusion Plasma sST2 levels were univariably associated with death or lung transplantation in PAH and CTEPH but were no longer prognostic after adjustment for age and NT-proBNP. The change in sST2 from baseline to follow-up did not predict transplant-free survival.
Background Lung transplant candidate selection relies on assessment of physiologic reserve, with body mass index commonly used to guide eligibility despite its limitations in distinguishing muscle from adipose tissue. CT-derived body composition analysis enables precise quantification of skeletal muscle and fat compartments. This study evaluates the association between CT-derived body composition metrics and transplant committee decisions. Methods We performed a retrospective cohort study of 704 adult lung transplant candidates evaluated from 2019-2024 with available preoperative abdominal CT imaging at a single academic institution. CT scans were analyzed using an automated deep learning workflow to quantify skeletal muscle, visceral fat, and subcutaneous fat at the third lumbar vertebral level. Metrics were normalized by age, sex, and race reference values. Patients were categorized as approved or denied using transplant committee decisions. Multivariable logistic regression with likelihood ratio testing was used to identify independent predictors of approval. Results Of 704 patients, 437 (62%) were approved and 267 (38%) were denied. Greater skeletal muscle area was independently associated with increased odds of transplant approval (per 50 cm2: OR 2.969, 95% CI 1.728-5.321, p<0.001). Visceral fat, subcutaneous fat, and body mass index category were not associated with approval. Skeletal muscle was lower in patients labeled as frail/deconditioned and positively associated with 6-minute walk distance (p<0.001). Conclusion CT-derived skeletal muscle is independently associated with lung transplant approval and may provide an objective marker of physiologic reserve that is not captured by body mass index, with potential to improve risk stratification in transplant candidate selection.
The pragmatic aspects of routine lung transplant recipient management are poorly described. We performed an international survey study to characterize management of stable lung transplant recipients who are beyond the initial post-transplant year. We obtained survey responses from 72 distinct lung transplant programs in 15 countries. Stable patients are monitored a median of every 3-months (IQR 3-3.25) in the ambulatory setting. Visits are accompanied by diagnostic laboratory assessments, spirometry, and chest X-ray imaging. Most centers perform between-clinic surveillance every 1-month (IQR 1-1.5) with diagnostic laboratory testing. We identified the frequency of monitoring of donor-specific antibodies [median 6 months (IQR 3-6)], chest computed tomography [median 12 months (IQR 12-12)], and other ancillary testing. A majority of stable patients are managed on a maintenance immunosuppression regimen of tacrolimus (preferred goal trough 8-10 ng/ml), mycophenolate, and prednisone (preferred dose of 5 mg daily). Dose reduction of immunosuppression occurs for cytopenias, recurrent infection, malignancy, and short telomere syndromes at most centers. Methodologies and frequencies for malignancy screening are described. While routine care of lung transplant recipients is heterogeneous, there are potential areas of consensus in practice patterns.
Background Venous thromboembolism (VTE) is a common complication following lung transplantation, and perioperative extracorporeal membrane oxygenation (ECMO) use has increased substantially over time. The relationship between ECMO exposure and early post-transplant VTE remains incompletely defined. Research Question Is perioperative ECMO utilization associated with an increased risk of VTE within 14 days of lung transplantation? Study Design and Methods A single center retrospective cohort study of adult lung transplants from 2010 to 2024 was performed. The primary outcome was the occurrence of a deep venous thrombosis (DVT) or pulmonary embolism (PE) within 14 days of transplant. Multivariable logistic regression was used to identify independent predictors of VTE during this time period and Cox proportional hazards models to evaluate the association between early VTE and survival. Results Among the 1083 lung transplant recipients, 22% developed VTE within 14 days. The incidence of VTE increased over time (11% in 2010-2013 vs. 38% in 2022-2024, p<0.001), paralleling the increase in ECMO utilization as well as implementation of a screening protocol. In adjusted analysis, both preoperative (adjusted OR 2.82, 95% CI 1.45-5.52) and intraoperative/postoperative ECMO exposures (adjusted OR 2.24, 95% CI 1.52-3.29) were independently associated with VTE. Early VTE was not associated with mortality (adjusted HR 0.87, 95% CI 0.67-1.12). Interpretation Early VTE after lung transplantation is common and has increased over time alongside increasing ECMO utilization. Perioperative ECMO exposure is independently associated with VTE. The findings highlight the need for targeted VTE prevention and surveillance strategies in lung transplant patients receiving ECMO support.
Background Outcomes after heart transplantation for anthracycline-induced cardiomyopathy (AICM) remain incompletely characterized, particularly compared with idiopathic dilated cardiomyopathy (DCM) and ischemic cardiomyopathy (ICM). Methods We analyzed adult first-time isolated heart transplant recipients in the Organ Procurement and Transplantation Network/United Network for Organ Sharing registry from January 1, 2000, to September 25, 2025. Recipients were grouped as AICM, idiopathic DCM, or ICM by registry diagnosis. The primary outcome was all-cause post-transplant mortality. Secondary outcomes included graft failure, post-transplant dialysis, stroke, pacemaker implantation, treated rejection, and length of stay. Results Compared with idiopathic DCM, AICM was not associated with higher adjusted mortality (HR 1.11, 95% CI 0.98-1.25; P=0.111) or graft failure (HR 1.09, 95% CI 0.96-1.23; P=0.185) but was associated with post-transplant dialysis (OR 1.31, 95% CI 1.03-1.67; P=0.030) and longer index hospitalization (IRR 1.12, 95% CI 1.06-1.18; P<0.001). AICM was also associated with higher malignancy-related mortality compared with idiopathic DCM (sHR 2.27, 95% CI 1.66–3.09; P<0.001) and ICM (sHR 1.70, 95% CI 1.24–2.33; P<0.001). Conclusions Among selected adult heart transplant recipients, anthracycline-induced cardiomyopathy was not associated with worse post-transplant survival or graft failure compared with idiopathic DCM. However, AICM recipients had higher adjusted odds of post-transplant dialysis, longer index hospitalization, and a greater burden of malignancy-related death, highlighting the need for individualized oncologic and renal-risk assessment in transplant candidates with prior anthracycline exposure.
