Long-term outcomes after cardiac transplantation: An experience based on different eras of immunosuppressive therapy

Background. Constantly changing practices in heart transplantation have imp roved posttransplant survival in patients with end-stage heart disease. The objective of this study was to evaluate long-term outcomes in different er as of immunosuppressive therapy after cardiac transplantation at a single c enter during a two-decade period. Methods. A retrospective review of 1,086 consecutive cardiac allograft reci pients who underwent transplantation between 1977 to 1999 was performed. Pa tients were divided into four eras based on type of immunosuppressive thera py: era 1 = steroids, azathioprine (n = 26, February 1977 to March 1983), e ra 11 = steroids, cyclosporine (n = 43, April 1983 to April 1985), era III = cyclosporine, steroids, azathioprine (n = 752, April 1985 to December 199 5), era IV = cyclosporine, steroids, mycophenolate mofetil (n = 315, Januar y 1996 to October 1999). Results. The actuarial survival of the entire cohort of 1,086 patients unde rgoing cardiac transplantation was 79%, 66%, and 49% at 1, 5, and 10 years, respectively. There were significant trends in recipient age and gender di stribution among the four eras with increasing proportion of older age (> 6 0 years) and female recipients in eras III and IV (p = 0.001 and 0.02). Ear ly mortality and long-term survival improved significantly over all eras (p < 0.001). Rejection as a cause of death decreased over time (era I, 24%; e ra II, 21%; era III, 15%; era IV, 9%; p = 0.02), whereas the contribution o f transplant coronary artery disease as a cause of death remained unchanged . Conclusions. Cardiac transplantation provides satisfactory long-term surviv al for patients with end-stage heart failure. The improving outcomes in sur vival correlate with improved immunosuppressive therapy in each era. Althou gh the reasons for improvement in survival over time are multifactorial, we believe that changes in immunosuppressive therapy have had a major impact on survival as evidenced by the decreasing number of deaths due to rejectio n. (C) 2001 by The Society of Thoracic Surgeons.