Preoperative INTERMACS Profiles Determine Postoperative Outcomes in Critically Ill Patients Undergoing Emergency Heart Transplantation: Analysis of the Spanish National Heart Transplant Registry

Background —Postoperative outcomes of advanced heart failure patients undergoing ventricular assist device implantation are strongly influenced by their preoperative INTERMACS profiles. We sought to investigate whether a similar association exists in patients undergoing emergency heart transplantation. Methods and Results —By means of the Spanish National Heart Transplant Registry database, we identified 704 adult patients treated with emergency heart transplantation in fifteen Spanish centers between 2000 and 2009. Post-transplant outcomes were analyzed with regard to patient preoperative INTERMACS profiles, which were retrospectively assigned by two blinded cardiologists. Before transplantation, INTERMACS profile 1 ("critical cardiogenic shock") was present in 207 patients, INTERMACS profile 2 ("progressive decline") in 291, INTERMACS profile 3 ("inotropic dependence") in 176 and INTERMACS profile 4 ("resting symptoms") in 30. In-hospital postoperative mortality rates were respectively 43%, 26.8% and 18% in patients with profiles 1, 2 and 3-4 (p<0.001). INTERMACS 1 patients also presented the highest incidence of primary graft failure (1: 31.3%, 2: 22.3%, 3-4: 21.8%, p=0.03) and postoperative need for dialysis (1: 33.2%, 2: 18.9%, 3-4: 21.5%, p <0.001). Adjusted odds-ratios for in-hospital postoperative mortality were 4.38 (CI95% 2.51-7.66) for profile 1 versus 3-4, 2.49 (CI 95% 1.56-3.97) for profile 1 versus 2 and 1.76 (CI95% 1.02-3.03) for profile 2 versus 3-4. Long-term survival after hospital discharge was not influenced by preoperative INTERMACS profiles. Conclusions —Preoperative INTERMACS profiles determine outcomes after emergency heart transplantation. Results call for a change in policies related to the management of heart transplant candidates presenting with INTERMACS profiles 1 and 2.