Revista Española de Cardiología (English Edition) Revista Española de Cardiología (English Edition)
Rev Esp Cardiol. 2018;71:952-60 - Vol. 71 Num.11 DOI: 10.1016/j.rec.2018.08.018

Spanish Heart Transplant Registry. 29th Official Report of the Spanish Society of Cardiology Working Group on Heart Failure

Francisco González-Vílchez a,, Luis Almenar-Bonet b, María G. Crespo-Leiro c, Luis Alonso-Pulpón d, José González-Costelo e, José Manuel Sobrino-Márquez f, José María Arizón del Prado g, Iago Sousa-Casasnovas h, Juan Delgado-Jiménez i, Félix Pérez-Villa j

a Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
b Hospital Universitario y Politécnico La Fe, Valencia, Spain
c Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
d Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Madrid, Spain
e Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
f Hospital Universitario Virgen del Rocío, Sevilla, Spain
g Hospital Universitario Reina Sofía, Córdoba, Spain
h Hospital Universitario Gregorio Marañón, Madrid, Spain
i Hospital Universitario 12 de Octubre, Madrid, Spain
j Hospital Universitari Clínic de Barcelona, Barcelona, Spain

Keywords

Heart transplant. Registry. Survival.

Abstract

Introduction and objectives

The present report updates the characteristics and results of heart transplantation in Spain, mainly focused in the 2008-2017 period.

Methods

We describe the recipient and donor characteristics, surgical procedures, and outcomes of heart transplants performed in 2017. The 2017 data were compared with those obtained from 2008 to 2016.

Results

A total of 304 cardiac transplants were performed in 2017. Between 1984 and 2017, 8173 procedures were performed, 2689 of them after 2008. Significant temporal trends were observed in recipient characteristics (lower pulmonary vascular resistance, lower use of mechanical ventilation, and a higher percentage of diabetic patients and those with previous cardiac surgery), donor characteristics (older donor age and a higher percentage of female donors and those with a prior cardiac arrest) and procedures (lower ischemia time). In 2017, 27% of patients were transplanted after undergoing mechanical ventricular assistance (P < .001 for trend). In the last decade, there was a trend to better survival.

Conclusions

Around 300 transplants per year were performed in Spain in the last decade. There was a significant increase in the use of pretransplant mechanical circulatory support and a trend to improved survival.

Article

INTRODUCTION

In the absence of contraindications, heart transplant is currently the recommended treatment for heart failure patients whose condition remains critical despite optimal medical and device therapy. In 2016, more than 7000 heart transplant procedures were performed worldwide, with more than a third of them in Europe.1 For low prevalence diseases and procedures such as heart transplant, one of the most effective ways to improve quality of care and clinical research is to maintain a clinical registry. These registries are especially valuable if they are comprehensive, like the Spanish Heart Transplant Registry (Registro Español de Trasplante Cardiaco [RETC]).

This annual report provides an update on the RETC, incorporating transplant data from 2017.

METHODS

Patients and Procedures

The data analyzed cover the clinical characteristics of recipients and donors, surgical procedures, immunosuppression, and mortality in the 18 active heart transplant programs in Spain (Table 1). Of the participating centers, 6 carry out pediatric heart transplants, 2 of them exclusively, and 2 of the centers carry out combined heart-lung transplants. The numbers of procedures performed since the first use of this therapeutic modality are summarized in Figure 1. Since 1984, 8173 heart transplant procedures have been carried out in Spain. The types of procedures performed in the whole series are summarized in Table 2.

Table 1. Centers Participating in the Spanish Heart Transplant Registry by Order of First Transplant Performed (1984-2017)

 

1. Hospital de la Santa Creu i Sant Pau, Barcelona
2. Clínica Universitaria de Navarra, Pamplona
3. Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Madrid
4. Hospital Marqués de Valdecilla, Santander
5. Hospital Reina Sofía, Córdoba (adults and pediatric)
6. Hospital Universitario y Politécnico La Fe, Valencia (adults and pediatric)
7. Hospital Gregorio Marañón, Madrid (adults and pediatric)
8. Fundación Jiménez Díaz, Madrid (1989-1994)
9. Hospital Virgen del Rocío, Seville
10. Hospital 12 de Octubre, Madrid
11. Hospital Universitario de A Coruña, La Coruña (adults and pediatric)
12. Hospital Bellvitge, L’Hospitalet de Llobregat, Barcelona
13. Hospital La Paz, Madrid (pediatric)
14. Hospital Central de Asturias, Oviedo, Asturias
15. Hospital Clínic, Barcelona
16. Hospital Virgen de la Arrixaca, El Palmar, Murcia
17. Hospital Miguel Servet, Zaragoza
18. Hospital Clínico, Valladolid
19. Hospital Vall d’Hebron, Barcelona (pediatric)

Yearly number of transplant procedures performed (1984-2017), in the total series and by age group.

Figure 1. Yearly number of transplant procedures performed (1984-2017), in the total series and by age group.

Table 2. Spanish Heart Transplant Registry (1984-2017). Procedure Type

 

Procedure 2017 1984-2017
De novo heart transplant 295 7806
Retrasplant 5 193
Combined retransplant 0 6 a
Combined transplant 4 162
Heart-lung 3 81
Heart-kidney 0 70 b
Heart-liver 1 11
Total 304 8161

a All were renal transplants.
b Heart retransplants are included.

The present report analyzes results from the past 10 years (2008-2017). To analyze time trends, most results were grouped into 3-year transplant periods (2008-2010, 2011-2013, and 2014-2016). The percentage of urgent transplants, the type of circulatory support, and donor age were analyzed by year of transplant.

The database structure and RETC practices concerning data collection, data handling, auditing, and data protection have been described previously.2 An effort has been made to present statistical data from before 2017 in a format consistent with previous studies; however, the process of continually updating the registry database may have led to the introduction of minor discrepancies in decimals. Nevertheless, any such minor discrepancies do not significantly affect the trends in proportions shown with this same updating procedure, which reveals large changes in pretransplant circulatory support (Figure 2).

Type of pretransplant circulatory support used by year (2008-2017). ECMO, extracorporeal membrane oxygenation; VAD, ventricular assist device.

Figure 2. Type of pretransplant circulatory support used by year (2008-2017). ECMO, extracorporeal membrane oxygenation; VAD, ventricular assist device.

Statistical Analysis

Continuous variables are expressed as mean ± standard deviation, and categorical variables as as percentages. Between-group differences in categorical variables were analyzed by the Kendall tau nonparametric test for a time series trend, whereas between-group differences in continuous variables were examined by analysis of variance with polynomial adjustment. Survival curves were calculated using the Kaplan-Meier method and were compared by the log-rank test. Differences were considered statistically significant at P < .05.

RESULTS

Recipient Characteristics

The main recipient characteristics by 3-year transplant period are summarized in Table 3. In 2017, there were 304 transplant procedures, 23 (7.6%) of them in recipients younger than 16 years. Approximately 3 of every 4 recipients were men, and mean recipient age was 48.5 (range, 0.05-73.0) years. The mean age of adult recipients was 51.8 years. Most procedures were de novo heart-only transplants (97%), with retransplants and combined transplants accounting for less than 3% of the total. Most combined transplant procedures were heart and lung or heart and kidney. These rates have remained largely unaltered since 2008.

Table 3. Recipient Characteristics in the Spanish Heart Transplant Registry (2008-2017)

 

  2008-2010 (n = 807) 2011-2013 (n = 732) 2014-2016 (n = 846) P (trend) 2017 (n = 304)
Age, y 49.8 ± 17.1 49.1 ± 17.1 49.7 ± 16.6 .9 48.5 ± 16.6
< 16 years 7.7 8.1 6.4 .29 7.6
 > 60 years 30.1 27.7 29.2 .69 24.7
Men 73.0 74.3 75.4 .26 72.4
BMI 25.0 ± 4.7 24.6 ± 4.8 24.6 ± 4.5 .11 25.0 ± 5.1
Underlying heart disease       .88  
Dilated nonischemic 35.9 35.8 37.1   38.2
Ischemic 37.8 35.5 37.0   31.3
Valvular 6.9 6.3 4.0   3.5
Other 19.3 22.4 21.9   27.0
PVR (WU) 2.5 ± 1.7 2.1 ± 1.2 2.2 ± 1.3 .001 2.1 ± 1.2
Creatinine > 2 mg/dL 5.6 5.0 6.0 .71 6.6
Bilirubin > 2 mg/dL 15.4 15.8 16.8 .48 19.6
Insulin-dependent diabetes 15.6 19.4 23.1 < .001 22.6
Moderate-severe COPD 9.3 8.7 11.7 .1 9.6
Previous infection 14.0 14.5 15.7 .31 15.8
Previous cardiac surgery 27.0 32.8 32.1 .025 36.6
Type of transplant       .85  
Single transplant 96.2 95.8 96.3   97.0
Retransplant 1.6 * 2.2 1.8   1.6
Combined 2.1 2.0 1.9   1.3
Heart-lung 1.1 0.9 1.0   1
Heart-kidney 0.7 * 0.9 0.7  
Heart-liver 0.2 0.1 0.2   0.3
Pretransplant mechanical ventilation 18.4 15.8 14.6 .04 11.8
Urgent transplant 34.3 41.1 46.3 < .001 44.4
Prettransplant circulatory support       < .001  
No support 73.6 65.7 61.1   60.9
Balloon pump 15.2 15.4 11.0   3.9
ECMO 4.5 8.7 10.8   8.2
Ventricular assist device 6.7 10.1 17.1   27.0

BMI, body mass index; COPD, chronic obstructive pulmonary disease; ECMO, extracorporeal membrane oxygenation; PVR, pulmonary vascular resistance.
Data are expressed as the percentage or the mean ± standard deviation.

* One patient with a heart retransplant combined with a kidney transplant.

Since 2008, there have been statistically significant trends toward lower pulmonary resistance (P < .001), increased percentages of recipients with diabetes (P < .001) and a history of cardiac surgery before transplant (P < .025), and a lower percentage of recipients receiving mechanical ventilation at the time of transplant (P < .04). Over the same period, there was an appreciable but nonsignificant trend toward an increase in the number of recipients with obstructive pulmonary disease (P < .10).

In 2017, 44% of transplant procedures were urgent (Figure 3), and 39.1% of transplant recipients received pretransplant circulatory support. Compared with previous years, there was a higher use of continuous-flow ventricular assist devices, with a marked reduction in the use of balloon pump counterpulsation. There were no changes in the use of extracorporeal membrane oxygenation (ECMO) and pulsatile-flow ventricular assist devices (Figure 2).

Percentage of urgent transplant procedures performed by year in the total series (2008-2017).

Figure 3. Percentage of urgent transplant procedures performed by year in the total series (2008-2017).

Donor Characteristics and Ischemia Time

Donor characteristics for the 3-year transplant periods and for 2017 are summarized in Table 4. The trend toward a higher mean donor age continued in 2017, with donors older than 45 years now accounting for 60% of the total (Figure 4). There was a further increase in the percentage of donors who died due to stroke (54.9%), accompanied by corresponding decreases in the percentage who died due to trauma (17.4%) and in the number of donors with pretransplant cardiac arrest. In contrast, cold ischemia time decreased slightly in 2017, with a decrease in ischemia times > 4 hours (25.3%) and an increase in times < 2 hours.

Table 4. Donor Characteristics and Ischemia Time in the Spanish Heart Transplant Registry (2008-2017)

 

  2008-2010 (n = 807) 2011-2013 (n = 732) 2014-2016 (n = 846) P (trend) 2017 (n = 304)
Age, y 37.4 ± 14.4 39.8 ± 15.6 43.3 ± 14.4 < .001 44.7 ± 14.0
Age > 45 years 35.2 41.8 54.1 < .001 59.9
Men 66.8 61.2 59 .001 60.9
Female donor-male recipient 18.3 23.4 24.8 .001 23.0
Weight, kg 72.7 ± 18.1 72.6 ± 18.6 74.6 ± 17.9 .03 74.7 ± 17.2
Recipient/donor weight 0.94 ± 0.2 0.94 ± 0.2 0.93 ± 0.2 .14 0.96 ± 0.2
Recipient/donor weight > 1.2 7.6 8.1 6.3 .27 10.9
Recipient/donor weight < 0.8 20.0 21.1 21.8 .38 21.1
Causeof death       .016  
Trauma 30.6 30.5 23.2   17.4
Stroke 44.1 46.4 50.7   54.9
Other 25.3 23.1 26.1   27.6
Pretransplant cardiac arrest a 10.1 12.4 16.8 < .001 19.4
Predonation echocardiography b       .09  
Not done 3.3 3.0 1.0   1.6
Normal 93.8 94 96.3   95.6
Mild generalized dysfunction 2.1 3.0 2.7   2.8
Ischemia time, min 212.4 ± 64.3 211.0 ± 60.1 197.7 ± 72.2 < .001 193.4 ± 71.1
≤ 120 min 9.8 8.9 16.3 .001 18.8
120-180 min 21.8 19.4 22.6   20.4
180-240 min 37.9 42.8 34.3   35.5
> 240 min 30.5 28.9 26.8   25.3

Data are expressed as the percentage or the mean ± standard deviation.

a Of 2129 transplant procedures.
b Of 2066 transplant procedures.

Yearly changes in donor age and percentage of donors older than 45 years (2008-2017). 95%CI, 95% confidence interval; ECMO, extracorporeal membrane oxygenation; VAD, ventricular assist device.

Figure 4. Yearly changes in donor age and percentage of donors older than 45 years (2008-2017). 95%CI, 95% confidence interval; ECMO, extracorporeal membrane oxygenation; VAD, ventricular assist device.

Immunosuppresion

The drugs used for induction immunosuppression during the study period are summarized in Table 5. As in previous years, induction therapy in 2017 mostly consisted of tacrolimus (90.5%), mycophenolate (and to a much lower extent mycophenolic acid) (96.6%), and steroids (98%). Approximately 85% of transplant recipients in 2017 also received antibody-based induction therapy, mostly basiliximab (76.1%).

Table 5. Induction Immunosuppression in the Spanish Heart Transplant Registry (2008-2017)

 

  2008-2010 (n = 807) 2011-2013 (n = 732) 2014-2016 (n = 846) P (trend) 2017 (n = 304)
Calcineurin inhibitors, %
Cyclosporine 35.5 23.6 8.0 < .001 5.8
Tacrolimus 59.5 72.3 89.2 < .001 90.5
Antiproliferative agents, %
MMF/MPS 94.6 96.4 96.2 .93 96.6
Azathioprine 2.5 0.3 0.9 .013 1.4
m-TOR inhibitors
Sirolimus 0.4 0.5 0.3 .58 1.2
Everolimus 3.0 1.6 1.7 .11 1.2
Steroids 97.8 97.5 98.0 .78 98.0
Induction       < .01  
Not used 12.0 14.1 15.4   15.9
ALG/ATG 5.2 2.4 3.2   5.0
Daclizumab 14.8 0.4 0.2   0.7
Basiliximab 67.1 83.0 80.8   76.1
Other 0.9 0.1 0.4   2.3

ALG, antilymphocyte globulin; ATG, antithymocyte globulin, MMF, mycophenolate mofetil; MPS, mycophenolate sodium.

Survival

Recipient survival in the 2008 to 2017 and 1984 to 2007 periods is compared in Figure 5. Compared with the earlier period, the 2008 to 2017 period showed a statistically significant improvement in survival, attributable to increased survival rates both at 1 year and over the longer term. The 1-year survival rate showed a mean improvement of 2.5%. Beyond the first year, the yearly death rate decreased from 2.2% to 1.6%. This trend toward improved survival continued within the 2008 to 2017 study period, approaching significance (P < .056) for the comparison between the 2014 to 2016 and 2008 to 2011 3-year transplant periods (Figure 6).

Comparison of survival curves for the 2008-2017 and 1984-2007 periods.

Figure 5. Comparison of survival curves for the 2008-2017 and 1984-2007 periods.

Comparison of survival curves for 2008-2016 by 3-year period.

Figure 6. Comparison of survival curves for 2008-2016 by 3-year period.

The dominant variables influencing survival during the study period were recipient age and the type of pretransplant circulatory support (Table 6). Compared with pediatric recipients (< 16 years old), recipients older than 60 years at the time of transplant had a 70% higher mortality risk (P < .001), whereas the increased risk in recipients between the ages of 16 and 60 years was  > 30% (P < .07). Previous ECMO increased the mortality risk by more than 40% (P < .008) compared with patients with no circulatory support device. However, results for recipients with a balloon pump or ventricular assist device were indistinguishable from those of patients with no support device (Table 6). During the 2008 to 2017 study period, there was no evidence that survival was influenced by donor age or urgent vs elective transplant.

Table 6. Univariate Survival Analysis by Baseline Characteristics of the Recipient, Donor, and Procedure (2008-2017)

 

  HR (95%CI) P Survival, y, median (95%CI)
Recipient age
< 16 y 1  
16-60 y 1.3 (1.0-1.8) .07
 > 60 y 1.7 (1.3-2.4) .001 9.2 (8.6-9.8)
Type of transplant
Single transplant 1  
Combined transplant 1.5 (1.0 -2.3) .06
Retrasplant 1.4 (0.9-2.2) .15
Donor age
≤ 45 y 1   10.0 (9.3-10.6)
 > 45 y 1.0 (0.9-1.1) .97 10.0 (9.2-10.8)
Urgency code
Elective 1  
Urgent 1.1 (1.0-1.3) .11 10.0 (9.4-10.7)
Type of support
No support 1  
Balloon pump 1.0 (0.8-1.3) .65
ECMO 1.4 (1.1-1.8) .008
Ventricular assist device 1.1 (0.9-1.3) .49

95%CI, 95% confidence interval; ECMO, extracorporeal membrane oxygenation; HR, hazard ratio.

Causes of Death

During the study period, the principal cause of death in the first posttransplant year was primary graft failure (32.6%), especially in the first month (43.5%), followed by infection (22.9%). Between the first and fifth posttransplant years, the most frequent causes of death were graft vascular disease/cardiac arrest (27.8%) and cancer (21.1%) (Figure 7). Overall, acute rejection caused 8% of posttransplant deaths, with the rate almost 3-fold higher (17.8%) between the first and fifth posttransplant years than in the first year (6.1%).

Main causes of death by time since transplant in the 2008-2017 period. CA, cardiac arrest; GVD, graft vascular disease.

Figure 7. Main causes of death by time since transplant in the 2008-2017 period. CA, cardiac arrest; GVD, graft vascular disease.

Almost all patients included in the present analysis survived the first year after transplant. Among those who did not, infection increased significantly as the cause of death between the 2008 to 2010 and 2011 to 2013 transplant periods, thereafter remaining stable (Figure 8). In contrast, primary graft failure showed a progressive and statistically significant decline as the cause of death in the first posttransplant year. Mortality due to transplant rejection has remained stable over the last decade (Figure 8).

Main causes of death occurring in the first year after transplant (2008-2016) by 3-year period. <i>P</i> values indicate the significance of the trend between 3-year periods, excluding 2017. Only 17 patients receiving a heart transplant in 2017 had completed ≥ 1-year follow-up at the time of database closure.

Figure 8. Main causes of death occurring in the first year after transplant (2008-2016) by 3-year period. P values indicate the significance of the trend between 3-year periods, excluding 2017. Only 17 patients receiving a heart transplant in 2017 had completed ≥ 1-year follow-up at the time of database closure.

DISCUSSION

Heart transplant activity in Spain has remained steady in recent years, at approximately 250 to 300 transplants a year. Given current donor characteristics and the exclusive sourcing of hearts from brain-dead donors, these figures are likely very close to the upper limit for heart transplant in Spain. Relaxation of the criteria for donor hearts, especially to allow donation after circulatory death, could increase organ supply, as demonstrated in small-scale studies in other countries.3 Organ supply could also be increased by routine use of coronary angiography in older donors or those with cardiovascular risk factors, who currently constitute the majority of heart donors in Spain.4

The data from 2017 confirm and in some instances reinforce the trends observed over the past decade. In addition to the increasing use of older donors who until recently would have been considered “borderline”, perhaps the most remarkable finding is the change in the type of circulatory support at the time of urgent intervention. The previous RETC report already revealed the worse short-term survival among recipients supported by ECMO than among those with ventricular assist devices.2 These findings were recently confirmed by a more comprehensive analysis of the RETC data5 and form the basis for the recent adjustment of the urgency code criteria, introduced by the Organización Nacional de Trasplantes (Spanish National Transplant Organization) in June 2017. Clinical stabilization with ventricular assist devices maintains the recipient in a better medical and hemodynamic condition during the transplant procedure, thus reducing the need for mechanical ventilation.6, 7 Using this approach, it is possible to achieve survival levels similar to those obtained after elective transplant.

The current data maintain the trend toward improved outcomes seen in previous reports. This trend did not reach statistical significance, probably due to the small sample size; nonetheless, the trend is apparent even over the past 10 years. The most notable development has been the reduction in early posttransplant mortality. This has been achieved largely through the progressive decline in deaths due to primary graft failure, as well as the stabilization of mortality due to infection and acute rejection. The declining rate of primary graft failure can be explained by improved prevention due to the decline in mean ischemia time, in combination with improved therapy through the broad implementation of circulatory support programs, which are especially effective for the treatment of this serious complication.8

CONCLUSIONS

Heart transplant activity in Spain has stabilized at approximately 250 to 300 procedures per year. In 2017, there was an increase in the prettransplant use of ventricular assist devices and a continuation of the trend to use organs from older donors. Recipient survival continued to show a trend toward progressive improvement.

CONFLICTS OF INTEREST

F. González-Vílchez has participated in Novartis educational presentations and has received compensation for travel costs from Pfizer and Bayer. M.G. Crespo-Leiro is the recipient of a CIBERCV grant, has participated in educational presentations for Novartis, Astellas, MSD, and Abbott, and has received compensation for travel costs from Novartis and Astellas. J. González-Costelo acts as a consultant for Alnylam, Abbot, Pfizer, and Novartis, has delivered lectures for Novartis, and has received compensation for travel costs from Astellas and Servier.

APPENDIX. COLLABORATORS IN THE SPANISH HEART TRANSPLANT REGISTRY, 1984-2017

 

Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Madrid Javier Segovia-Cubero, Manuel Gómez-Bueno, Francisco Hernández-Pérez
Hospital Universitario y Politécnico La Fe, Valencia Soledad Martínez-Penades, Mónica Cebrián-Pinar, Raquel López-Vilella, Ignacio Sánchez-Lázaro, Luis Martínez-Dolz
Complejo Hospitalario Universitario de A Coruña, A Coruña María J Paniagua-Martín, Eduardo Barge-Caballero, Gonzalo Barge-Caballero, David Couto-Mallón
Hospital Universitario Reina Sofía, Córdoba Amador López-Granados, Carmen Segura-Saintgerons, Dolores Mesa, Martín Ruiz, Elías Romo, Francisco Carrasco, José López-Aguilera
Hospital Universitario Marqués de Valdecilla, Santander Manuel Cobo, Miguel Llano-Cardenal, José A. Vázquez de Prada, Francisco Nistal-Herrera
Hospital Gregorio Marañón (adults), Madrid María Jesús Valero, Juan Fernández-Yáñez, Paula Navas, Carlos Ortiz, Adolfo Villa, Eduardo Zataraín, Manuel Martínez-Sellés
Hospital Universitario 12 de Octubre, Madrid María Dolores García-Cosío, Laura Morán-Fernández, Zorba Blázquez
Hospital de la Santa Creu i Sant Pau, Barcelona Eulàlia Roig-Minguell, Vicens Brossa-Loidi, Sonia Mirabet-Pérez, Laura López-López
Hospital Universitario Virgen del Rocío, Sevilla Ernesto Lage-Gallé, Diego Rangel-Sousa
Hospital Universitario de Bellvitge, L’Hospitalet de Llobregat, Barcelona Nicolás Manito-Lorite, Carles Díez-López, Josep Roca-Elías
Clínica Universitaria de Navarra, Pamplona Gregorio Rábago-Aracil
Hospital Clínic Universitari, Barcelona María Ángeles Castel, Marta Farrero, Ana García-Álvarez
Hospital Universitario Central de Asturias, Oviedo José Luis Lambert-Rodríguez, Beatriz Díaz-Molina, María José Bernardo-Rodríguez
Hospital Universitario Gregorio Marañón (pediatric), Madrid Manuela Camino-López, Juan Miguel Gil-Jaurena, Nuria Gil-Villanueva
Hospital Universitario Virgen de la Arrixaca, El Palmar, Murcia Iris Garrido-Bravo
Hospital Universitario Miguel Servet, Zaragoza Teresa Blasco-Peiró, Ana Pórtoles-Ocampo, Marisa Sanz-Julve
Clínico Universitario, Valladolid Luis de la Fuente-Galán, Javier Tobar-Ruiz, Ana María Correa-Fernández
Hospital Universitario La Paz, Madrid Luis García-Guereta Silva, Álvaro González-Rocafort, Carlos Labradero-de Lera, Luz Polo- López
Hospital Universitario Vall d’Hebron, Barcelona Dimpna C. Albert-Brotons, Ferrán Gran-Ipiña, Raúl Abella-Antón

Corresponding author: Servicio de Cardiología, Hospital Universitario Marqués de Valdecilla, Avda. Valdecilla s/n, 39008 Santander, Cantabria, Spain. cargvf@gmail.com

Bibliography

1. Newsletter Transplant. International figures of donation and transplantation 2016. Available at: http://www.ont.es/publicaciones/Documents/NEWSLETTER%202017_baja%20(2).pdf. Accessed 18 Jul 2018.
2. González-Vílchez F, Gómez-Bueno M, Almelnar-Bonet L, et al. Registro Español de Trasplante Cardiaco. XXVIII Informe Oficial de la Sección de Insuficiencia Cardiaca de la Sociedad Española de Cardiología (1984-2016). Rev Esp Cardiol. 2017;70:1098-109.
3. Messer SJ, Axell RG, Colah S, et al. Functional assessment and transplantation of the donor heart after circulatory death. J Heart Lung Transpl. 2016;35:1443-52.
4. Organización Nacional de Trasplantes. Memoria de Actividad. ONT 2016. Available at: http://www.ont.es/infesp/Memorias/Memoria%20Donaci%C3%B3n%202016.pdf. Accessed 25 May 2018.
5. Barge-Caballero E, Almenar-Bonet L, Gonzalez-Vilchez F, et al. Clinical outcomes of temporary mechanical circulatory support as a direct bridge to heart transplantation: a nationwide Spanish registry. Eur J Heart Fail. 2018;20:178-86.
6. Sánchez-Enrique C, Jorde UP, González-Costelo J. Trasplante cardiaco y soporte circulatorio mecánico para pacientes con insuficiencia cardiaca avanzada. Rev Esp Cardiol. 2017;70:371-81.
7. Gómez Bueno M, Segovia-Cubero J, Serrano Fiz S, et al. Experiencia con una asistencia ventricular pulsátil de larga duración como puente al trasplante cardiaco en adultos. Rev Esp Cardiol. 2017;70:727-35.
8. Phan K, Luc JG, Xu J, et al. Utilization and outcomes of temporary mechanical circulatory support for graft dysfunction after heart transplantation. ASAIO J. 2017;63:695-703.

1885-5857/© 2018 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved

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