The report was produced using the methods described in past editions.1 The number of Spanish hospitals running active heart transplant programs in 2018 remained stable at 18. Of these hospitals, 2 perform pediatric transplants only, 4 perform pediatric and adult transplants, and 2 perform cardiopulmonary transplants (table 1). Between 1984 and 2018, 8494 transplants were performed across Spain (figure 1). The types of transplant performed during this period and in 2018 in particular are summarized in table 2. This report presents data for 2018 and draws comparisons with the period spanning 2009-2018. To detect trends over this decade, data were analyzed by 3-year periods (2009-2011, 2012-2014, and 2015-2017) for all data except percentage of urgent transplants, type of circulatory support used in patients awaiting transplant, and donor age, which were analyzed on a yearly basis.

Figure 1.

Annual number of transplants performed between 1984 and 2018 for the entire series and for patients aged over 60 and under 16 years.

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Continuous and categorical variables are expressed as mean (SD) and percentages, respectively. Between-group differences were analyzed using the Kendall Tau nonparametric test to determine the significance of time series trends for categorical data and by analysis of variance with polynomial contrasts for continuous data. Survival curves were calculated using the Kaplan-Meier method and compared with the logrank test. Differences were considered statistically significant at a P value of less than .05.

Recipient characteristics are summarized in table 3. A total of 321 transplants were performed in 2018. Compared with 2017, there was a 42% increase in recipients older than 60 years and a 52% increase in those younger than 16 years. Mean (SD) age was 49 (19) years and 70.7% of the recipients were men. The proportion of combined transplants and retransplants remained stable at around 3% of the total. In the 10-year period spanning 2009-2018, there was a significant trend towards improved pretransplant renal function (P=.03) and an increased proportion of recipients with diabetes (P<.001). A nonsignificant trend was observed for increased pretransplant bilirubin levels (P=.07) and more heart surgery procedures among those waiting for a transplant (P=.06).

Pretransplant circulatory support was required in 43.5% of recipients. Intra-aortic balloon pump counterpulsation (IABP) practically disappeared as a means of circulatory support in 2018, and there was an increase in the use of extracorporeal membrane oxygenation (ECMO) and ventricular assist devices (VADs) (figure 2). Most of the VADs were continuous-flow devices. Almost half the transplants performed in 2018 were urgent (47.4%), maintaining the trend observed for 2009-2018 (figure 3).

Figure 2.

Type of pretransplant circulatory support between 2008 and 2017. ECMO, extracorporeal membrane oxygenation; VAD, ventricular assist device.

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Figure 3.

Percentage of urgent transplants performed annually for the full series (2009-2018).

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Donor characteristics are summarized in table 4. While donors were slightly younger in 2018 compared with 2017, the trend towards a higher donor age in the past decade remained highly significant. Over 50% of donors in 2018 were older than 45 years (figure 4). The trend towards an increasing proportion of donors who died of stroke and a decrease in those who died of trauma remained highly significant, as did the increase in donors with pretransplant cardiac arrest (P<.001). There was also an increase in cold ischemia time from 2017 to 2018, mainly attributable to more transplants with an ischemia time of over 3hours and fewer transplants with an ischemia time of under 2hours.

Figure 4.

Annual changes in donor age and percentage of donors older than 45 years from 2009 to 2018. 95%CI, 95% confidence interval; ECMO, extracorporeal membrane oxygenation; VAD, ventricular assist device.

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The drugs used for induction immunosuppression are summarized in table 5. The main ones used in 2018 are similar to those from the preceding 10 years and included tacrolimus, mycophenolate, and steroids. The proportion of patients who received antibody-based induction therapy (mainly with basiliximab) was also similar.

Survival rates were significantly higher in 2009-2018 than in 1984-2008 (figure 5). Both early survival (first year after transplant) and medium-term survival (first 5 years after transplant) improved. Overall, survival improved progressively over the decade, with a significant difference (P=.005) observed for outcomes between 2015-2017 and 2009-2011 (figure 6).

Figure 5.

Comparison of survival curves between 1984-2008 and 2009-2018.

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Figure 6.

Comparison of survival curves between 3-year periods from 2009 to 2017.

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The factors influencing survival in 2009-2018 (table 6) were very similar to those identified in the previous decade.2 Donor age, at least during the period contemplated, did not have any prognostic significance. A recipient age of over 60 years, by contrast, had a significantly greater influence on survival than one of under 16 years (P=.001). Combined transplants were associated with significantly worse survival than single transplants, primarily due to poorer cardiopulmonary transplant outcomes. Finally, patients who underwent an urgent transplant had a 20% increased likelihood of dying than those who underwent an elective transplant. This higher risk is attributable to transplant outcomes in patients supported by pretransplant ECMO, who had a 70% higher risk of death compared with those who underwent elective transplant.

The main causes of death in the first 5 years following transplant were primary graft failure, infection, and graft vascular disease/cardiac arrest (figure 7). The main cause of death in the first month was primary graft failure, which was responsible for 40.9% of all deaths. The other main causes of death were infection between months 2 and 12 (39.2%) and graft vascular disease/cardiac arrest between years 1 and 5 (28.2%). Acute rejection was responsible for 7.8% of all deaths, and together with cancer, it was the second most common cause of death between 1 and 5 years posttransplant (19.2% in both cases).

Figure 7.

Main causes of death by time since transplant for 2009-2018. CA, cardiac arrest; GVD, graft vascular disease.

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Trends in causes of death in year 1 were analyzed, as most patients survived this period (figure 8). The importance of primary graft failure as a cause of death in the first year after transplant decreased very significantly over the decade analyzed (P=.001): it caused 39.3% of deaths in 2009-2011 versus 23.1% of deaths in 2015-2017, and the downward trend continued in 2018 (22.0%). By contrast, there was a nonsignificant trend towards an increase in the importance of infection as a cause of death in the first year posttransplant over the 10 years analyzed. In this case, infection caused 19.7% of deaths in 2009-2011, 28.4% in 2015-2017, and 36.0% in 2018. Acute rejection as a cause of death remained stable over the decade and caused no deaths in 2018.

Figure 8.

Main causes of death in year 1 posttransplant shown by 3-year periods for 2009-2017.

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