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Cardiac Amyloidosis: No Longer a Barrier to Heart Transplant
Matthew T. McGoldrick1, Eric W. Etchill2, Katherine Giuliano1, Gayane Yenokyan3, Ahmet Kilic2
1Johns Hopkins School of Medicine, Baltimore, MD, USA, 2Johns Hopkins Hospital, Baltimore, MD, USA, 3Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

OBJECTIVE: The incidence of amyloidosis is increasing, and restrictive cardiomyopathy (RCM) as a complication of cardiac amyloidosis is an increasingly common indication for heart transplant. Although older studies suggest that amyloidosis may be a contraindication to transplant, careful selection of RCM-amyloidosis patients now yields short- and medium-term outcomes comparable to those in non-amyloidosis patients. METHODS: This study utilized the Organ Procurement and Transplantation database to retrospectively assess survival trends among all adult patients with a primary diagnosis of RCM-amyloidosis receiving a first time heart transplant from 1999-2020. We examined outcomes by year and by transplant era (1999-2001, 2002-2008, 2009-2015, 2015-2019). Multivariable Cox regression was used to evaluate survival while logistic regression was used to measure secondary outcomes.
RESULTS: Of 41,707 patients, 440 (1.1%) were transplanted for a primary indication of RCM-amyloidosis. Analysis of all patients showed that amyloidosis was associated with a 29% increased risk of mortality at ten years (p=.0009), but not with increased risk of mortality at one (p=.42) or five (p=.06) years (Figure 1). When divided by transplant era, RCM-amyloidosis patients experienced increased risk of mortality at five years in the 1999-2001 and 2002-2008 periods, but not during the 2009-2015 and 2016-2019 periods (Table 1).
CONCLUSIONS: While five-year outcomes among RCM-amyloidosis patients prior to 2008 were inferior to non-amyloidosis patients, there is no difference in five-year outcomes between groups in the most recent transplant era. Contemporary evidence suggest that selected patients receiving a transplant for cardiac amyloidosis now experience survival comparable to that of all other patients.

Table 1. Risk of mortality for patients with cardiac amyloidosis compared to all other patients.
One YearFive Year
Hazard RatioP-Value% SurvivalHazard RatioP-Value% Survival
1999 - 20012.760.10762.5%3.30.00553.9%
2002 - 20081.17.72581.4%1.86.01454.2%
2009 - 20151.06.83088.9%1.06.27057.4%
2015 - 20191.330.36486.9%1.280.34076.9%

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