A summary has already been published of the main methods used in the Spanish Heart Transplant Registry.3 In 2019, an adult heart transplant program was started in Dr Negrin University Hospital of Gran Canaria, bringing the total number of active centers to 19. There have been no changes from previous years in the structure of the activity of the distinct hospitals (eg, pediatric transplant, multiorgan transplant)4,5 (table 1). From 1984 to 2019, 8794 transplants were performed (figure 1); the Spanish Heart Transplant Registry has complete follow-up information on 8782 of these transplants, which form the basis of the current analysis. The types of transplants performed in 2019 and in the entire series are summarized in table 2. This report provides the relevant data for 2019 and compares them with those of the last 10 years (2010-2019). The changes over time for the period under study were analyzed in 3-year periods (2010-2012, 2013-2015, and 2016-2018), except for the percentage of urgent transplants, the types of pretransplant circulatory support, and donor age, which were analyzed by year.

Figure 1.

Annual number of transplants (1984-2019), total and by age group.

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Continuous variables are expressed as mean ± standard deviation, whereas categorical variables are expressed as percentages. Differences among time periods were analyzed using a nonparametric test for time series data (Kendall τ) for categorical variables and ANOVA (analysis of variance) with polynomial fit for continuous variables. Survival curves were calculated using the Kaplan-Meier test and were compared using a log-rank test. P < .05 was considered statistically significant.

Recipient characteristics are summarized in table 3. A total of 300 transplants were performed in 2019. Compared with 2018, the decrease in the number of procedures was mainly due to fewer pediatric patients (younger than 16 years old). The mean recipient age was 49.5 ± 17.8 years, with no significant changes in the last 10 years. Overall, 72.3% were men, confirming the trend in the last decade for an increase, albeit nonsignificant, in transplants in women. The percentages of multiorgan transplants and retransplants were stable, at about 2% overall. In the last 10 years, the only significant trends were the improvement in renal function at transplant and the increase in pretransplant cardiac surgery (both P = .04). The latter variable was correlated with increased use of ventricular assist devices in 2019, with a tendency for a slight decrease in the use of extracorporeal membrane oxygenation (figure 2). There was a major decrease in urgent procedures in 2019 (38.0%) vs the tendency of previous years (46.8% in 2016-2018) (figure 3).

Figure 2.

Type of pretransplant circulatory support by year (2010-2019). ECMO, extracorporeal membrane oxygenation; VAD, ventricular assist device.

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Figure 3.

Percentage of urgent transplants performed annually for the full series (2010-2019).

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Donor characteristics are summarized in table 4. Donor age was stable vs the previous 3-year period, although the tendency for an increase in the last 10 years was highly significant. In 2019, 55% of donors were older than 45 years of age (figure 4). There was a slight decrease in the number of donors who died of stroke, with a corresponding increase in those who died of other causes. There was another small but consistent increase in the number of donors with pretransplant cardiac arrest (18% in 2019), although there was also a decrease in donors with mild dysfunction on pretransplant echocardiography. The cold ischemia time fell again, a tendency seen in the last 10 years, with an average time in 2019 of a little more than 3hours In addition, almost 3 of every 4 transplants were performed with a bicaval technique, a trend that now appears established.

Figure 4.

Annual changes in donor age and percentages of donors older than 45 years (2010-2019). 95%CI, 95% confidence interval.

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Induction immunosuppression strategies are summarized in table 5. In 2019, the tendencies seen in the last decade were confirmed, with the almost exclusive use of triple therapy comprising tacrolimus, mycophenolate, and steroids. Likewise, more than 80% of patients received antibody-based induction therapy, mainly basiliximab.

Survival was significantly better from 2010 to 2019 than from 1984 to 2009 (figure 5). This improvement was evident in both early survival (first posttransplant year) and mid-term survival (until the fifth posttransplant year). The final 3-year period (2016-2018) showed a significant improvement in survival vs the 2010 to 2012 period, although survival was similar to that of the immediately preceding period (2013-2015) (figure 6).

Figure 5.

Comparison of survival curves between the periods 2010 to 2019 and 1984 to 2009.

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Figure 6.

Comparison of survival curves from 2010 to 2018 by 3-year period.

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Factors related to survival from 2010 to 2019 (table 6) were maintained at similar levels to those of previous reports.3 The most notable result was that recipient age was associated with survival, unlike donor age. Recipient age > 60 years exerted a highly significantly effect on survival vs age < 16 years (P = .004). As in previous analyses, combined transplant and urgent transplant, due to the effect of pretransplant extracorporeal membrane oxygenation, continued to be associated with worse survival vs heart transplant alone and elective transplant, respectively.

Infection, primary graft failure, and graft vascular disease/cardiac arrest were the most frequent causes of death in the first 5 posttransplant years during the last decade (figure 7). As expected, death from primary graft failure was concentrated in the first posttransplant month, causing a third of deaths. The leading cause of death in the period between the first month and first posttransplant year was infection (40.8% of cases), but was graft vascular disease/cardiac arrest between the first and fifth years (28.9%). These proportions mirror those observed in previous reports, as do the high incidence of death due to acute rejection observed between the first and fifth posttransplant years (18.6%) and that due to cancer in the same period.

Figure 7.

Main causes of death by time since transplant in the 2010 to 2019 period. GVD/CA, graft vascular disease/cardiac arrest.

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Mortality in the first year due to primary graft failure and acute rejection stabilized in 2019. In contrast, 2019 showed a reduction of almost one-half in patients who died of infection in this early period (figure 8).

Figure 8.

Changes over time in the main causes of death in the first posttransplant year from 2010 to 2018 by 3-year period.

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