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Pages 962-970 (November 2021)
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Vol. 74. Issue 11.
Pages 962-970 (November 2021)
Special article
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Spanish Heart Transplant Registry. 32nd Official Report of the Heart Failure Association of the Spanish Society of Cardiology
Registro Español de Trasplante Cardiaco. XXXII Informe Oficial de la Asociación de Insuficiencia Cardiaca de la Sociedad Española de Cardiología
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Francisco González-Vílcheza,
Corresponding author
cargvf@gmail.com

Corresponding author: Servicio de Cardiología, Hospital Universitario Marqués de Valdecilla, Avda. Valdecilla s/n, 39008 Santander, Cantabria, Spain.
, Luis Almenar-Bonetb, María G. Crespo-Leiroc,d, Manuel Gómez-Buenoe, José González-Costellof, Félix Pérez-Villag, Juan F. Delgado-Jiménezh,d, José M. Arizón del Pradoi, José M. Sobrino-Márquezj, María Jesús Valero-Masak, on behalf of the Spanish Heart Transplant Teams
a Servicio de Cardiología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
b Servicio de Cardiología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
c Servicio de Cardiología, Complexo Hospitalario Universitario A Coruña (CHUAC), Universidade da Coruña (UDC), Instituto de Investigación Biomédica A Coruña (INIBIC), A Coruña, Spain
d Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
e Departamento de Cardiología, Hospital Universitario Clínica Puerta de Hierro-Majadahonda, Majadahonda, Madrid, Spain
f Servei de Cardiologia, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
g Servei de Cardiologia, Hospital Clínic Universitari, Barcelona, Spain
h Servicio de Cardiología, Fundación Investigación Hospital Universitario 12 de Octubre, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
i Servicio de Cardiología, Hospital Universitario Reina Sofía, Córdoba, Spain
j Servicio de Cardiología, Hospital Universitario Virgen del Rocío, Sevilla, Spain
k Servicio de Cardiología, Hospital Universitario Gregorio Marañón, Madrid, Spain
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Tables (7)
Table 1. Centers participating in the Spanish Heart Transplant Registry from 1984 to 2020 (by order of first transplant performed)
Table 2. Spanish Heart Transplant Registry (1984-2020). Type of procedure
Table 3. Recipient characteristics in the Spanish Heart Transplant Registry (2011-2020)
Table 4. Donor characteristics and procedure times in the Spanish Heart Transplant Registry (2011-2020)
Table 5. Induction immunosuppressive in the Spanish Heart Transplant Registry (2011-2020)
Table 6. Univariate analysis of survival by the baseline characteristics of the recipient, donor, and procedure (2011-2020)
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Abstract
Introduction and objectives

The present report updates the main characteristics and outcomes of heart transplants in Spain to 2020.

Methods

We describe the main features of recipients, donors, surgical procedure, and immunosuppression in 2020. We also analyze the temporal trends of these characteristics and outcomes (survival) for the period 2011 to 2019.

Results

In 2020, 278 heart transplants were performed (7.3% decrease vs 2019). The findings in 2020 confirmed previous observations of an increase in pretransplant sternotomy, a slight decrease in urgent transplants carried out with ventricular assist devices, a slight decrease in donor age, an increase in the use of allografts with previous arrest, and a decrease in ischemia time. Survival continued to improve in recent triennia, reaching 82.0% at 1 year in the period 2017 to 2019.

Conclusions

The slight decrease in the number of heart transplants performed in 2020 in Spain, most likely due to the SARS-CoV-2 pandemic, did not change the main characteristics of the procedure. No change was observed in the tendency to improved survival.

Keywords:
Heart transplant
Registry
Survival
Resumen
Introducción y objetivos

Se actualizan las características y los resultados del trasplante cardiaco en España con los hallazgos de los procedimientos realizados en 2020.

Métodos

Se describen las características de receptores, donantes, procedimiento quirúrgico e inmunosupresión en el año 2020. Se analizan las tendencias de estas características y los resultados (supervivencia) en el último periodo 2011-2019.

Resultados

En 2020 se han realizado 278 trasplantes cardiacos (un 7,3% menos que el año anterior). Los hallazgos de 2020 confirman las tendencias previas a un aumento de la esternotomía previa, una discreta disminución del trasplante urgente realizado sobre todo con dispositivos de asistencia ventricular, una ligera disminución de la edad del donante con aumento del uso de donantes con parada cardiaca previa y una disminución del tiempo de isquemia. La supervivencia continúa mejorando en los últimos trienios y alcanza el 82,0% al primer año en el trienio 2017-2019.

Conclusiones

La ligera disminución en la actividad del trasplante cardiaco en España en 2020, en relación con la pandemia por SARS-CoV-2, no ha cambiado las principales características del procedimiento. No se detectan cambios en la tendencia a la mejora de la supervivencia de los pacientes trasplantados.

Palabras clave:
Trasplante cardiaco
Registro
Supervivencia
Full Text
INTRODUCTION

The Spanish Heart Transplant Registry (Registro Español de Trasplante Cardiaco) has published an annual report every year since 1991 on heart transplant activity and outcomes in Spain. This document includes all heart transplants performed in Spain since transplant activity began here in 1984. The report is hugely valuable for detecting problems and opportunities in transplant patient care and has established itself as a driver of clinical research.1–3

The present article provides an update on the data from previous years, including the procedures performed in 2020, paying particular attention to the results obtained in the last decade.

METHODSPatients and procedures

Data related to the characteristics of recipients, donors, surgical procedures, immunosuppression, and outcomes of all procedures are collected in a pre-established, Excel-based electronic database that can be accessed online. Updating this registry at least once per year is mandatory for participating centers. The Spanish Heart Transplant Registry is anonymized for patients, has been approved by an ethics committee, and is registered by the Spanish Society of Cardiology with the Spanish Ministry of Health as outlined in the Organic Law on Data Protection. The database is the property of the Spanish Society of Cardiology. Database maintenance, quality assurance, and statistical analysis are performed by an external contract research organization. The only significant change to the current database is related to the cutoff age for defining pediatric transplants, which is now 18 years, in line with the change made by the Spanish National Transplant Organization and is aimed at standardizing our data with those of international registries.

Currently, 19 centers have an active heart transplant program (table 1). Of these, 2 perform pediatric transplants alone (which is also performed in 4 other centers with an adult program) and 2 centers are equipped to perform cardiopulmonary transplants. The types of transplants performed in 2020 and in the entire series are summarized in table 2. With 278 transplants performed in 2020 (10.4% in recipients younger than 18 years and 26.9% in those older than 60 years), the Spanish Heart Transplant Registry includes 9060 procedures (figure 1). The outcomes from 2020 are compared with those from the previous decade segmented into 3-year periods (2011-2013, 2014-2016, and 2017-2019). The changes over time in the percentages of urgent transplants, the type of pretransplant circulatory support, and donor age were analyzed by year.

Table 1.

Centers participating in the Spanish Heart Transplant Registry from 1984 to 2020 (by order of first transplant performed)

1.  Hospital de la Santa Creu i Sant Pau, Barcelona 
2.  Clínica Universitaria de Navarra, Pamplona 
3.  Clínica Puerta de Hierro-Majadahonda, Majadahonda, Madrid (adult, cardiopulmonary) 
4.  Hospital Marqués de Valdecilla, Santander 
5.  Hospital Reina Sofía, Córdoba (adult and pediatric) 
6.  Hospital Universitario y Politécnico La Fe, Valencia (adult and pediatric, cardiopulmonary) 
7.  Hospital Gregorio Marañón, Madrid (adult and pediatric) 
8.  Fundación Jiménez Díaz, Madrid (1989-1994) 
9.  Hospital Virgen del Rocío, Sevilla 
10.  Hospital 12 de Octubre, Madrid 
11.  Hospital Universitario de A Coruña, A Coruña (adult and pediatric) 
12.  Hospital de Bellvitge, L’Hospitalet de Llobregat, Barcelona 
13.  Hospital La Paz, Madrid (pediatrics) 
14.  Hospital Central de Asturias, Oviedo 
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 (pediatrics) 
20.  Hospital de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria 
Table 2.

Spanish Heart Transplant Registry (1984-2020). Type of procedure

Procedure  2020  1984-2020 
De novo heart transplant  269  8678 
Heart retransplant alone  204 
Combined heart retransplant  7* 
Combined de novo heart transplant  171 
Heart-lung  85 
Heart-kidney  74 
Heart-liver  12 
Total  278  9060 
*

All renal transplants.

Figure 1.

Annual number of transplants (1984-2020); total and by age group.

(0.25MB).
Statistics

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 temporal trends (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.

RESULTSRecipient characteristics

In total, 278 transplants were performed in 2020, 7.3% less than in the previous year. The fall in the number of transplants was largely due to a decrease in April (figure 2). Recipient characteristics in 2020 and in the previous decade are summarized in table 3. At the time of transplantation, 10.2% of recipients were younger than 18 years and 26.9% were older than 60 years. The overall mean age was 48.7 years, similar to that of the previous decade; 33.1% were women. Almost one-third of the procedures were performed for heart diseases with etiologies other than ischemic or nonischemic dilated cardiomyopathy and in patients with previous cardiac surgery. In total, 39% of procedures were urgent (table 3); these procedures were largely performed with circulatory support via ventricular assist devices (figure 3). The percentage of urgent transplants has returned to the levels recorded at the start of the decade (about 38%), after a period (2013 and 2018) when it almost reached 50% (figure 4). In the last decade, there were no significant changes in the main characteristics of recipients, except an increase in the percentage of patients with previous cardiac surgery and a change in the type of pretransplant circulatory support, with the almost complete disappearance of the balloon pump and an increase in ventricular assist devices, mainly continuous flow (figure 3).

Figure 2.

Number of transplants per month in 2019 and 2020.

(0.15MB).
Table 3.

Recipient characteristics in the Spanish Heart Transplant Registry (2011-2020)

  2011-2013 (n=732)  2014-2016 (n=846)  2017-2019 (n=925)  P for trend  2020 (n=278) 
Age, y  49.1±17.1  49.7±17.1  49.2±17.7  .44  48.7±17.9 
<18 y, %  8.7  7.7  9.1  .77  10.4 
> 60 y, %  27.7  29.2  30.4  .58  27.0 
Male sex  74.3  75.4  71.8  .17  66.9 
BMI  24.6±4.8  24.6±4.5  24.8±4.9  .27  24.7±5.0 
Underlying etiology, %        .99   
Nonischemic dilated  35.1  36.4  36.9    38.1 
Ischemic  35.4  36.9  31.6    29.1 
Other  29.5  26.7  31.6    32.7 
PVR, UW  2.1±1.2  2.2±1.4  2.1±1.3  .70  2.0±1.2 
Glomerular filtration rate, mL/min/1.73 m2  78.1±36.2  79.4±35.7  80.2±37.8  .32  80.1±41.0 
Bilirubin> 2 mg/dL  16.2  17.1  15.2  .83  10.4 
Insulin-dependent diabetes  19.3  22.8  20.1  .98  18.3 
Moderate-severe COPD  8.7  11.5  10.4  .42  7.5 
Previous infection  14.8  15.6  13.3  .96  14.8 
Previous cardiac surgery  32.4  32.1  37.5  <.001  32.1 
Type of transplant, %        .72   
Isolated transplant  95.8  96.3  96.7    96.8 
Heart retransplant  2.2  1.8  2.2    2.2 
Combined  1.9  1.9  1.1    1.0 
Heart-lung  1.2  0.9  1.0    0.7 
Heart-kidney  0.7  0.7  0.7    0.3 
Heart-liver  0.1  —  0.3   
Pretransplant mechanical ventilation  15.8  14.5  15.4  .55  12.2 
Urgent transplant  41.4  46.3  43.0  .42  38.9 
Pretransplant circulatory support        <.001   
No  65.6  61.0  59.3    68.4 
Balloon pump  15.5  11.3  1.9    0.7 
ECMO  6.4  10.8  10.1    7.3 
Ventricular support  9.3  17.2  28.8    23.6 

BMI, body mass index; COPD, chronic obstructive pulmonary disease; ECMO, extracorporeal membrane oxygenation; PVR, pulmonary vascular resistance.

Values are expressed as percentage or mean ± standard deviation.

Figure 3.

Distribution of the type of pretransplant circulatory support by year (2011-2020). ECMO, extracorporeal membrane oxygenation; VAD, ventricular assist device.

(0.18MB).
Figure 4.

Annual percentage of urgent transplants in the total population (2011-2020).

(0.12MB).
Donor and surgical procedure characteristics

The characteristics of the donors and surgical procedures are summarized in table 4. Once again, a high percentage of transplants involved donors older than 45 years, which represented almost half of the patients. Nonetheless, after a peak in 2017, the subsequent years showed a slight decreasing tendency in the percentage of older donors (figure 5). As in previous years, the trends show a high percentage of transplants involving donors who had a preprocedural cardiac arrest or who died of stroke.

Table 4.

Donor characteristics and procedure times in the Spanish Heart Transplant Registry (2011-2020)

  2011-2013 (n=732)  2014-2016 (n=846)  2017-2019 (n=925)  P for trend  2020 (n=278) 
Age, y  39.7±14.6  43.4±14.3  43.2±15.4  <.001  42.2±14.9 
Age> 45 y  41.8  54.3  56.5  <.001  48.9 
Male sex  61.2  58.9  62.0  .92  56.5 
Female donor-male recipient  23.4  24.9  21.4  .47  19.8 
Weight, kg  72.6±18.6  74.7±17.9  74.5±19.8  .04  73.1±19.1 
Recipient/donor weight  0.94±0.20  0.93±0.19  0.93±0.20  .68  0.93±0.20 
Recipient/donor weight> 1.2  9.4  6.9  8.4  .09  8.3 
Recipient/donor weight <0.8  21.0  22.0  23.9  .12  24.1 
Cause of death        <.001   
Trauma  30.8  23.3  19.7    20.9 
Stroke  57.0  63.0  64.8    66.9 
Other  12.2  13.7  15.6    12.2 
Pretransplant cardiac arresta  12.4  16.6  18.7  <.001  20.9 
Predonation echocardiogramb        .16   
Not performed  2.9  1.0  1.7    0.0 
Normal  94.3  96.5  95.7    100.0 
Mild generalized dysfunction  2.8  2.5  2.6    0.0 
Ischemia time, min  210.9±60.0  197.7±72.2  197.0±72.8  <.001  193.5±70.8 
≤ 120 min  8.9  12.5  17.9  <.001  16.2 
120-180 min  19.4  22.5  19.8    22.3 
180-240 min  42.9  38.3  34.7    40.6 
> 240 min  28.8  26.7  27.7    220.9 
Bicaval surgical technique  68.5  70.1  71.6  .77  79.7 

Values are expressed as percentage or mean ± standard deviation.

a

Of 2725 transplants.

b

Of 2468 transplants.

Figure 5.

Annual changes in donor age and in the percentages of donors older than 45 years (2011-2020). 95%CI, 95% confidence interval.

(0.15MB).

The mean ischemia time has tended to fall in the last decade due to an increase in procedures with short ischemia times ( 120minutes) and a decrease in interventions with moderately long times (180-240minutes). In 2020, 4 of every 5 transplants were performed with a bicaval technique.

Immunosuppression

Induction immunosuppression in 2020 was in line with that observed in the previous 3-year period (2017-2019; table 5). The use of cyclosporin was very low (about 5%) and almost entirely limited to patients with adverse reactions to tacrolimus. Likewise, the use of azathioprine was barely recorded in the last decade. More than 80% of patients received antibody-based pretransplant induction therapy, mainly basiliximab.

Table 5.

Induction immunosuppressive in the Spanish Heart Transplant Registry (2011-2020)

  2011-2013(n=732)  2014-2016(n=846)  2017-2019(n=925)  P for trend  2020(n=278) 
Calcineurin inhibitors
Cyclosporin  22.6  7.8  4.7  <.001  5.9 
Tacrolimus  77.4  92.2  95.3  <.001  94.1 
Antiproliferative agents
Mycophenolate/mycophenolic acid  99.7  99.1  99.2  .95  98.9 
Azathioprine  0.3  0.9  0.8  .95  1.1 
mTOR inhibitors
Sirolimus  0.4  0.3  0.4  .19  0.4 
Everolimus  1.5  1.6  1.4  .41  0.4 
Corticoids  98.6  98.5  98.5  .60  98.1 
Induction        .03   
No  10.6  12.6  15.1    15.9 
ALG/ATG  2.5  3.3  4.3    2.3 
Anti-CD25  86.4  83.7  79.3    81.8 
Other  0.4  0.4  1.3    0.0 

ALG, antilymphocyte globulin; anti-CD25, basiliximab, daclizumab; ATG, antithymocyte globulin.

Values are expressed as percentages.

Survival

In the last decade, survival was about 80% in the first posttransplant year and was more than 70% at 5 years, which was significantly higher than that recorded in the entire previous series (figure 6A). From the last decade, the most recent 3-year period (2017-2019) showed significantly higher survival vs the 2011 to 2013 period and nonsignificantly higher survival vs the 2014 to 2016 period (figure 6B). The 1-year survival rates in the 2011 to 2013, 2014 to 2016, and 2017 to 2019 periods were 77.7%, 78.9%, and 82.0%, respectively. As in previous years, the main univariable predictors of mortality were recipient age and urgent transplant, largely due to the higher mortality of recipients who received circulatory support with extracorporeal membrane oxygenation (table 6).

Figure 6.

A: comparison of survival curves between the 2011 to 2020 and 1984 to 2010 periods. B: comparison of survival curves in the 2011 to 2019 period by 3-year period.

(0.2MB).
Table 6.

Univariate analysis of survival by the baseline characteristics of the recipient, donor, and procedure (2011-2020)

  Hazard ratio (95%CI)  P 
Recipient age
<18 y   
19-60 y  1.8 (0.9-1.8)  .07 
> 60 y  1.9 (1.4-2.6)  <.001 
Type of transplant
Isolated transplant   
Combined transplant  1.4 (0.9-83.97)  .18 
Retransplant  1.3 (0.8-2.1)  .27 
Donor age
≤ 45 y   
> 45 y  1.1 (0.9-1.2)  .27 
Transplant urgency
Elective   
Urgent  1.2 (1.0-1.4)  .03 
Type of support
No support   
Balloon pump  0.9 (0.7-1.2)  .47 
ECMO  1.6 (1.3-2.0)  <.001 
Ventricular support  1.2 (0.9-1.4)  .10 

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

Causes of death

In the first 5 posttransplant years, almost half of deaths were due to primary graft failure or infection (figure 7), with primary graft failure concentrated in the first posttransplant month and infection in the remainder of the first year. Acute graft rejection was a major cause of death between the first and fifth post-transplant year (16.4%), only surpassed by combined sudden cardiac death/graft vascular disease (25.4%) and cancer (20.0%). These trends are similar to those recorded in the most recent registry analyses.

Figure 7.

Main causes of death according to time since transplantation in the 2011 to 2020 period.

(0.14MB).

The trends in the posttransplant causes of death were analyzed only for those occurring in the first year, because complete information was available from this period for all patients (figure 8). The last decade showed a nonsignificant tendency for a decrease in primary graft failure as the cause of death, particularly since 2013, with infection and rejection maintained. Death due to rejection fell by almost half in the 2017 to 2019 period vs the previous 3-year period, although the difference was not significant due to the small number of events.

Figure 8.

Changes over time in the main causes of death in the first post-transplant year in the 2011 to 2020 period by 3-year period.

(0.12MB).
DISCUSSION

In all settings and particularly in the health care field, 2020 has been heavily affected by the impact of the SARS-CoV-2 pandemic. Heart transplant activity has been no exception, with the number of procedures falling in 2020 vs 2019. Nonetheless, it must be highlighted that this decrease can be considered slight and, furthermore, generally limited to April and May (the latter month with less intensity), given that the activity recovered in the following months. We believe these data to be highly valuable, particularly given that transplant activity greatly depends on the activity of intensive care units, and to undoubtedly reflect the efficacy of a mature system with a very strong involvement of all of its participants.

The clinically most relevant trends in the last 10 years regarding recipient characteristics, which seem to be confirmed by the data from 2020, are related to the increased percentage of patients with previous sternotomy, a factor with prognostic implications,4 and the increased percentage of transplants performed with ventricular assist devices, which specifically require sternotomy. The latter has been accompanied by the almost complete disappearance of the balloon pump as a pretransplant circulatory support device. In addition, the percentage of transplants performed under urgent conditions has shown a biphasic behavior in the last decade, with a growing tendency until 2016 and a decrease since then, particularly since 2018. Undoubtedly, these trends have been influenced by the modification of the inclusion criteria for the urgent transplant list from the middle of 2017. A similar biphasic behavior with a less obvious explanation was observed for donor age, with a peak in 2017 and a slow progressive decrease until 2020. This finding may have a positive impact on the prognosis of our patients, particularly in the mid- and long-term.2 A variable related to donor age is cause of death, with stroke being the leading cause of death. However, this variable has exhibited a tendency for stabilization in the last two 3-year periods, which is clearly related to the variations in donor age. Finally, the last decade has shown an increase in the number of procedures performed with very short ischemia times ( 120minutes), due to decreases in those with moderately long times (180-240minutes), which can at least partly explain the improved survival outcomes found in our analysis.1

As in previous reports,5,6 we once again observed a significant trend for improved survival, which, in the last 3-year period analyzed, exceeded 80% in the first year. This improvement must be attributed to the slow progressive change in donor, recipient, and surgical procedure characteristics, as well as, highly probably, the familiarization of transplant teams with the increasingly complex clinical environment of contemporary heart transplantation. Nonetheless, a deeper investigation of this topic is impeded by the nature of the present report. Finally, in future reports, it will be possible to evaluate the possible impact of the SARS-CoV-2 pandemic on our results.

CONCLUSIONS

Heart transplant activity fell slightly in 2020 due to the SARS-CoV-2 pandemic. Nonetheless, the clinical results continue to show a tendency for progressive improvement.

FUNDING

The present article did not receive funding.

AUTHORS’ CONTRIBUTIONS

All authors have contributed to the data collection, have critically revised the manuscript, and have approved its publication in the current form. F. González-Vílchez was responsible for the preparation of the manuscript.

CONFLICTS OF INTEREST

None.

Appendix A
APPENDIX 1. Collaborators in the Spanish Heart Transplant Registry 1984-2020

Center  Collaborators 
Hospital Universitario Marqués de Valdecilla, Santander  Manuel Cobo-Belaustegui, Miguel Llano-Cardenal, José Antonio Vázquez de Prada, Francisco Nistal-Herrera 
Hospital Universitario Central de Asturias, Oviedo  José Luis Lambert-Rodríguez, Beatriz Díaz-Molina, Cristina Fidalgo-Muñiz 
Hospital Universitario Virgen del Rocío, Sevilla  Diego Rangel-Sousa, Antonio Grande-Trillo 
Hospital de la Santa Creu i Sant Pau, Barcelona  Vicens Brossa-Loidi, Sonia Mirabet-Pérez, Laura López, Isabel Zegrí, Marta de Antonio 
Hospital Clínic Universitari, Barcelona  María Ángeles Castel, Marta Farrero 
Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Barcelona  Nicolás Manito, Carles Díez, Elena García-Romero, Josep Roca 
Hospital General Universitario Gregorio Marañón, Madrid (adults)  Javier Castrodeza, Iago Sousa, Zorba Blázquez, Eduardo Zataraín, Jorge García-Carreño, Paula Navas, Miriam Juárez, Carlos Ortiz, Manuel Martínez-Sellés 
Hospital Univesitari i Politècnic La Fe, Valencia  Mónica Cebrián, Raquel López-Viella, Ignacio Sánchez-Lázaro, Sol Martínez, Víctor Donoso, Luis Martínez 
Hospital Universitario Reina Sofía, Córdoba  Amador López-Granados 
Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Madrid  Javier Segovia-Cubero, Francisco Hernández-Pérez, Cristina Mitroi, Mercedes Rivas-Lasarte 
Hospital Universitario 12 de Octubre, Madrid  María Dolores García-Cosío, Laura Morán-Fernández, Pedro Caravaca, Juan Carlos López-Azor 
Complejo Hospitalario Universitario de A Coruña, A Coruña  María Jesús Paniagua-Martín, Eduardo Barge-Caballero, Gonzalo Barge-Caballero, David Couto-Mallón, José Cuenca-Castillo, José María Herrera-Noreña 
Hospital Universitario La Paz, Madrid  Luis García-Guereta Silva, Óscar González-Fernández, Inés Ponz de Antonio, Carlos Labrandero de Lera, Álvarez González-Rocafort, Luz Polo-López 
Hospital General Universitario Gregorio Marañón, Madrid (pediatric)  Manuela Camino-López, Nuria Gil-Villanueva 
Hospital Clínico Universitario, Valladolid  Luis de la Fuente-Galán, Javier Tobar-Ruiz 
Hospital Universitario Virgen de la Arrixaca, El Palmar, Murcia  Iris P. Garrido-Bravo, Domingo A. Pascual-Figal, Francisco J. Pastor-Pérez 
Hospital Universitario Miguel Servet, Zaragoza  Teresa Blasco-Peiró, Ana Pórtoles-Ocampo, María Lasala-Alastuey 
Clínica Universitaria, Pamplona  Gregorio Rábago-Juan-Aracil, Rebeca Manrique-Antón, Leticia Jimeno-San Martín 
Hospital Universitario Doctor Negrín, Las Palmas de Gran Canaria  Antonio García-Quintana, María del Val Groba-Marco, Mario Galván-Ruiz 
Hospital Universitari Vall d’Hebron, Barcelona  Ferrán Gran-Ipiña, Paola Dolader 

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F. González-Vílchez, L. Almenar-Bonet, M.G. Crespo-Leiro, Spanish Heart Transplant Registry. 30th Official Report of the Spanish Society of Cardiology Working Group on Heart Failure (1984-2018), et al.
Rev Esp Cardiol., 72 (2019), pp. 954-962
[6]
F. González-Vilchez, L. Almenar-Bonet, M.G. Crespo-Leiro, et al.
Spanish Heart Transplant Registry. 31st Official Report of the Heart Failure Association of the Spanish Society of Cardiology.
Rev Esp Cardiol., 73 (2020), pp. 919-926

The affiliations of the collaborators are listed in Appendix 1.

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