1
|
Martens S, Tie H, Kehl HG, Tjan TD, Scheld HH, Martens S, Hoffmeier A. Heart transplantation surgery in children and young adults with congenital heart disease. J Cardiothorac Surg 2023; 18:342. [PMID: 38012741 PMCID: PMC10683181 DOI: 10.1186/s13019-023-02461-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 11/15/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Pediatric cardiac transplantation remains a surgical challenge as a variety of cardiac and vessel malformation are present in patients with congenital heart disease (CHD). Despite limited availability and acceptability of donor hearts, the number of heart transplantations remains on a stable level with improved survival and quality of life. OBSERVATION As treatment options for CHD continue to improve and the chances of survival increase, more adult CHD patients are listed for transplantation. This review focuses on the clinical challenges and modified techniques of pediatric heart transplantations. CONCLUSION Not only knowledge of the exact anatomy, but above all careful planning, interdisciplinary cooperation and surgical experience are prerequisites for surgical success.
Collapse
Affiliation(s)
- Sabrina Martens
- Department of Cardiothoracic Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Hongtao Tie
- Department of Cardiothoracic Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Hans Gerd Kehl
- Department of Pediatric Cardiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Tonny Dt Tjan
- Department of Cardiothoracic Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Hans Heinrich Scheld
- Department of Cardiothoracic Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Sven Martens
- Department of Cardiothoracic Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany
| | - Andreas Hoffmeier
- Department of Cardiothoracic Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany.
| |
Collapse
|
2
|
Bradford TT, Daily JA, Lang SM, Gossett JM, Tang X, Collins RT. Comparison of inhospital outcomes of pediatric heart transplantation between single ventricle congenital heart disease and cardiomyopathy. Pediatr Transplant 2019; 23:e13495. [PMID: 31169342 DOI: 10.1111/petr.13495] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 03/25/2019] [Accepted: 04/23/2019] [Indexed: 11/29/2022]
Abstract
Data investigating the impact of household income and other factors on SV patient status-post-Fontan palliation after heart transplantation are lacking. We aim to evaluate factors affecting outcomes after OHT in this population. The PHIS database was interrogated for either SV or myocarditis/primary CM who were 4 years or older who underwent a single OHT. There were 1599 patients with a median age of 13.2 years (IQR: 9.3-16.1). Total hospital costs were significantly higher in the SV group ($408 000 vs $294 000, P < 0.0001), but as median household income increased, the risk of inhospital mortality, post-transplant LOS, and LOS-adjusted total hospital costs all decreased. The risk of inhospital mortality increased 6.5% per 1 year of age increase at the time of transplant. Patients in the SV group had significantly more diagnoses than those in the CM group (21 vs 15, P < 0.0001) and had longer total hospital LOSs as a result of longer post-transplant courses (25 days vs 15, P < 0.0001). Increased median household income and younger age are associated with decreased resource utilization and improved inhospital mortality in SV CHD patients who undergo OHT. In conclusion, earlier consideration of OHT in this population, coupled with improved selection criteria, may increase survival in this population.
Collapse
Affiliation(s)
- Tamara T Bradford
- University of Arkansas for Medical Sciences, Little Rock, Arkansas.,Arkansas Children's Research Institute, Little Rock, Arkansas
| | - Joshua A Daily
- University of Arkansas for Medical Sciences, Little Rock, Arkansas.,Arkansas Children's Research Institute, Little Rock, Arkansas
| | - Sean M Lang
- University of Cincinnati College of Medicine, Cincinnati, Ohio.,Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jeffrey M Gossett
- University of Arkansas for Medical Sciences, Little Rock, Arkansas.,Arkansas Children's Research Institute, Little Rock, Arkansas
| | - Xinyu Tang
- University of Arkansas for Medical Sciences, Little Rock, Arkansas.,Arkansas Children's Research Institute, Little Rock, Arkansas
| | - R Thomas Collins
- Stanford University School of Medicine, Palo Alto, California.,Lucile Packard Children's Hospital Stanford, Palo Alto, California
| |
Collapse
|
3
|
Moosdorf R. [Artificial heart and heart transplantation]. Herz 2012; 37:869-74. [PMID: 23104433 DOI: 10.1007/s00059-012-3702-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The advances in the treatment of many different heart diseases have on the one side led to a significant prolongation of life expectancy but have also contributed to an increase of patients with heart failure. This tendency is supported even more so by the demographic development of our population. The replacement of insufficient organs has always been in the focus of medical research. In the 1960's Shumway and Lower developed the technique of cardiac transplantation and also worked intensively on the treatment and diagnosis of rejection. However, it was Barnard who, in 1967 performed the first human cardiac transplantation. Other centers followed worldwide but the mortality was high and the new therapy was controversially discussed in many journals. By the introduction of cyclosporin as a new immunosuppressive agent in 1978, results improved rapidly and cardiac transplantation became an accepted therapeutic option for patients with end stage heart failure and also for children and newborns with congenital heart defects. Today, with newer immunosuppressive regimens and improved techniques, cardiac transplantation offers excellent results with a long-term survival of nearly 50% of patients after 15 years and among the pediatric population even after 20 years. However, the donor organ shortage as well as the increasing number of elderly patients with end stage heart failure has necessitated work on other alternatives. Neither stem cell transplantation nor xenotransplantation of animal organs are yet an option and there are still some obstacles to be overcome. In contrast, the development of so-called artificial hearts has made significant progress. While the first implants of totally artificial hearts were associated with many comorbidities and patients were seriously debilitated, new devices today offer a reasonable quality of life and long-term survival. Most of these systems are no longer replacing but mainly assisting the heart, which remains in place. These ventricular assist devices have been used as a bridge to transplantation for a long time and are now also offered as a destination therapy for patients who for a variety of reasons are no longer amenable to heart transplantation. Further miniaturization and a decrease of the costs will make these devices a realistic alternative to a sole medical therapy and studies have already proven the superiority in terms of survival as well as rehospitalization rates. However, at present they are still not an alternative to heart transplantation.
Collapse
Affiliation(s)
- R Moosdorf
- Klinik für Herz- und thorakale Gefäßchirurgie, UKGM - Universitätsklinik Marburg, Baldingerstr. 1, 35033, Marburg, Deutschland.
| |
Collapse
|
4
|
Hoskote A, Carter C, Rees P, Elliott M, Burch M, Brown K. Acute right ventricular failure after pediatric cardiac transplant: predictors and long-term outcome in current era of transplantation medicine. J Thorac Cardiovasc Surg 2009; 139:146-53. [PMID: 19910002 DOI: 10.1016/j.jtcvs.2009.08.020] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2008] [Revised: 07/03/2009] [Accepted: 08/10/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To identify pretransplant factors associated with postprocedural right ventricular failure and the relationship between right ventricular failure and long-term survival in children. METHODS Records were reviewed for children having heart transplantation from 2000 to 2006. RESULTS Right ventricular failure was identified by clinical and echocardiographic parameters in 33/129 (25%) recipients: dilated cardiomyopathy in 14/90 (15%), congenital heart disease in 11/27 (41%), and restrictive cardiomyopathy in 8/12 (66%). In 9 of 12 (75%), known elevated (reactive) pulmonary vascular resistance progressed to right ventricular failure. In a further 23/117 (20%) recipients, pulmonary vascular resistance within predefined acceptable range progressed to right ventricular failure. Multiple logistic regression analyses indicated elevated pulmonary vascular resistance (odds ratio 12.30; 95% confidence interval 2.73, 55.32; P = .001) and primary diagnosis, restrictive cardiomyopathy (odds ratio 9.21; 95% confidence interval 2.07, 41.12; P = .004), and congenital heart disease (odds ratio 4.07; 95% confidence interval 1.36, 12.19; P = .012) were strongly associated with right ventricular failure, but duration of heart failure, pretransplant mechanical support, donor status, and ischemic times were not. Treatment included inhaled nitric oxide in 28 (84%), mechanical support in 10 (31%), hemofiltration in 13 (40%), and retransplantation in 2. A Cox multiple regression model including: primary diagnosis, right ventricular failure, and elevated pulmonary vascular resistance indicated that only the latter was independently linked with eventual mortality (hazards ratio 5.45; 95% confidence interval 1.36, 21.96; P = .017). CONCLUSIONS Primary diagnosis and pretransplant elevated reactive pulmonary vascular resistance are both linked to the evolution of right ventricular failure. Pulmonary vascular resistance assessment in end-stage heart failure is challenging; therefore, avoidance of right ventricular failure may not always be possible. Aggressive early treatment may mitigate the effects of right ventricular failure: pretransplant elevated pulmonary vascular resistance was independently associated with long-term survival, but right ventricular failure was not.
Collapse
Affiliation(s)
- Aparna Hoskote
- Cardiac Critical Care Unit, Great Ormond Street Hospital for Children NHS Trust, Great Ormond Street, London WC1N 1JH, United Kingdom.
| | | | | | | | | | | |
Collapse
|
5
|
Jayakumar KA, Addonizio LJ, Kichuk-Chrisant MR, Galantowicz ME, Lamour JM, Quaegebeur JM, Hsu DT. Cardiac transplantation after the Fontan or Glenn procedure. J Am Coll Cardiol 2004; 44:2065-72. [PMID: 15542293 DOI: 10.1016/j.jacc.2004.08.031] [Citation(s) in RCA: 187] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2003] [Revised: 07/21/2004] [Accepted: 08/09/2004] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The purpose of this study was to review the clinical course and outcome of cardiac transplantation after a failed Glenn or Fontan procedure. BACKGROUND Late complications of the Glenn or Fontan procedure, including ventricular failure, cyanosis, protein-losing enteropathy, thromboembolism, and dysrhythmias often lead to significant morbidity and mortality. If other therapies are ineffective, cardiac transplantation is the only therapeutic recourse. Transplantation in this unique population presents significant challenges in the operative and perioperative periods. METHODS The anatomic diagnoses, previous operations, clinical status, and indications for transplantation were characterized in patients transplanted after a Glenn or Fontan procedure. Outcomes after transplantation, including postoperative complications and mortality, were reviewed. Comparisons were made between survivors and nonsurvivors. RESULTS Primary orthotopic cardiac transplantation was performed in 35 patients (mean age 15.7 +/- 8.5 years) with a mean follow-up of 54 +/- 46 months. A total of 11 patients had undergone a Glenn shunt and 24 patients a Fontan procedure. Indications for transplantation were a combination of causes including ventricular dysfunction, failed Fontan physiology, and/or cyanosis. Ten patients died <or=2 months after transplantation; nine of the deaths occurred in the Fontan patients. Overall, one-year survival was 71.5%, and five-year survival was 67.5%. Survival was not significantly different between patients transplanted after a Glenn or Fontan procedure and patients transplanted for other etiologies. CONCLUSIONS Cardiac transplantation can be performed successfully in patients with end-stage congenital heart disease after a Glenn or Fontan procedure, with outcomes similar to transplantation for end-stage heart failure secondary to other etiologies.
Collapse
Affiliation(s)
- K Anitha Jayakumar
- Department of Pediatrics, College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | | | | | | | | | | | | |
Collapse
|
6
|
Schindler E, Müller M, Akintürk H, Valeske K, Bauer J, Zickmann B, Hempelmann G. Perioperative management in pediatric heart transplantation from 1988 to 2001: anesthetic experience in a single center. Pediatr Transplant 2004; 8:237-42. [PMID: 15176960 DOI: 10.1111/j.1399-3046.2004.00155.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Pediatric cardiac transplantation is currently an accepted option for end-stage heart disease and congenital cardiac malformations. This report focuses on the anesthetic perioperative management in 12 yr. From 1988 to 2001 we performed 90 heart transplantations in 88 children, infants and neonates. The pediatric heart transplant program of the children's heart center at our university hospital started in June 1988 with the transplantation of a 2-yr-old boy who was suffering from congenital heart disease. Since then, 88 transplants have been performed. We divided our patients into two groups. Group 1 ranged from 1988 to 1996 and Group 2 from 1997 to 2001. The patient characteristics have not significantly changed over the years in our institution. At the time of transplantation, mean age of the patients was 2.6 +/- 4.3 yr from the period of 1988-1996 and 2.5 +/- 4.1 yr from 1997 to 2001. Since 1988, 90 transplants (Tx) in 88 patients have been performed. Two patients needed re-Tx within 2 days after the initial operation because of primary graft failure. Indications for Tx were congenital heart disease (n = 67) and cardiomyopathy (n = 21). In the subgroup of the patients suffering from congenital heart disease there were 46 with the diagnosis of HLHS, followed by endocardial fibroelastosis (n = 7); the remaining 14 patients had other complex cardiac malformations and some underwent corrective palliative cardiac surgery before Tx. Sixty-three patients were younger than 1 yr of age and only five children were older than 10 yr. Twenty-three percent of the patients on the waiting list died before Tx was possible. The overall survival rate was 79% at 1 yr and 73% at 5 and 10 yr. Infants with HLHS had a lower probability of survival after 5 yr compared with other diagnosis (69% vs. 84%). Until now 21 patients have died after Tx. The duration of anesthesia, time of CPB and the age at the time of surgery decreased over the years. It is always a challenge for the anesthesiologist to treat these patients with pulmonary hypertension as one of the most critical risks in this group of patients. The preventive therapy with vasodilators as well as the availability of mechanical assist devices before and after heart transplantation reduces the effects of transitional pulmonary hypertension and prevents the development of post-operative right heart failure.
Collapse
Affiliation(s)
- Ehrenfried Schindler
- Department of Anesthesiology and Intensive Care Medicine, Asklepios Klinik Sankt Augustin, German Pediatric Heart Center, Sankt Augustin, Germany.
| | | | | | | | | | | | | |
Collapse
|
7
|
Goldberg CS, Gomez CA. Hypoplastic left heart syndrome: new developments and current controversies. ACTA ACUST UNITED AC 2003; 8:461-8. [PMID: 15001118 DOI: 10.1016/s1084-2756(03)00116-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2003] [Accepted: 07/01/2003] [Indexed: 11/17/2022]
Abstract
Prior to 1980, the diagnosis of hypoplastic left heart syndrome (HLHS) was almost uniformly lethal. Over the past 25 years, the development of operative options, including staged surgical palliation and infant heart transplant, have resulted in major improvements in survival and quality-of-life outcomes. Throughout this period, the optimal treatment strategy for children with HLHS has continued to be controversial. Current advances include fetal diagnosis, medical management, catheter intervention and operative techniques, and hold great promise for further improvements. However, as new techniques continue to evolve, controversies will continue to arise. This article will explore the treatment strategies for children with HLHS and review current controversies surrounding this complex congenital cardiac disease.
Collapse
Affiliation(s)
- Caren S Goldberg
- Department of Pediatrics and Communicable Diseases, Division of Pediatric Cardiology and the Congenital Heart Center, C. S. Mott Children's Hospital, University of Michigan Medical Center, Ann Arbor, MI 48109-0204, USA.
| | | |
Collapse
|
8
|
Dapper F, Bauer J, Kroll J, Zickmann B, Bohle RM, Hagel KJ, Schranz D. Clinical experience with heart transplantation in infants. Eur J Cardiothorac Surg 1998; 14:1-5; discussion 5-6. [PMID: 9726607 DOI: 10.1016/s1010-7940(98)00136-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Orthotopic heart transplantation has become an accepted therapeutic concept for adult patients with endstage heart disease. In newborns and infants this procedure is still a matter of discussion because of unknown long-term results and the lack of donor organs. METHODS Since March 1988 we have performed 40 orthotopic heart transplantation in 39 infants who were from 1 to 280 days of age. Indications for transplantation included hypoplastic left-heart syndrome (n = 28), dilative cardiomyopathy (n = 4), endocardial fibroelastosis (n = 4) and other complex structural anomalies (n = 3). The mean waiting period for transplantation was 53 days. A donor-recipient weight ratio up to 4.0 was accepted. Profound hypothermic circulatory arrest was used for graft implantation in all those patients who required extensive aortic arch reconstruction (71%). The initial immunomodulation was based on Cyclosporine, Azathioprine and Prednisolone. Patients who underwent transplantation during the first 6 weeks of life received a chronic single-drug therapy with Cyclosporine after 1 year. RESULTS There were six peri-operative deaths caused by drug-resistant right-heart failure in three cases, humoral rejection (n = 1), CMV infection (n = 1) and multi organ failure (n = 1). One infant died late, due to rejection. The actuarial survival rate for the entire group is now 82%. There is a remarkable influence of increasing experience. Whereas six of 15 infants who had heart transplantation between 1988 and 1993 died early post-operatively (survival rate: 60%), only one late death occurred among 24 recipients in the period from 1994 to April 1997 (survival rate: 96%). Episodes of rejection occurred once or several times in about half of the patients in this series (48%). All surviving children are living at home in excellent condition. CONCLUSIONS Heart transplantation during early infancy is a rational and durable therapy for heart diseases with irreversible myocardial failure or severe structural anomalies. The intermediate-term results have been encouraging in many centers, but more data must be accumulated to determine the sequelae of chronic immunosuppression. The lack of donor organs remains one of the major problems in pediatric heart transplantation.
Collapse
Affiliation(s)
- F Dapper
- Department of Cardiovascular Surgery, Justus-Liebig-University, Giessen, Germany.
| | | | | | | | | | | | | |
Collapse
|
9
|
Au J, Gregory JW, Colquhoun IW, Scott CD, Hilton CJ, Hunter S, Dark JH. Paediatric cardiac transplantation with steroid-sparing maintenance immunosuppression. Arch Dis Child 1992; 67:1262-6. [PMID: 1444525 PMCID: PMC1793932 DOI: 10.1136/adc.67.10.1262] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
In order to determine the results of steroid-sparing maintenance immunosuppression in paediatric patients who have undergone orthotopic heart transplantation (OHT), a retrospective study was undertaken in 12 children and five infants (median age 3.5 years). Preoperative diagnoses were cardiomyopathy in seven and congenital heart disease in 10 patients. Immunosuppression was induced by cyclosporin, azathioprine, methylprednisolone, and antihuman lymphocyte immune globulin. It was maintained with cyclosporin and azathioprine. After induction, five patients received no further steroids. The remainder, except one, required only pulses for rejection (13 episodes or 0.51 episodes/patient year). Long term complications included hypertension in six, and renal impairment in three children. There were no early or late deaths from infection. Actuarial survival was 94% at one year. Of the children followed up for more than one year, all demonstrated an increase in height SD scores (mean (SD) -2.15 (1.35) to -1.15 (1.16)). We conclude that a steroid-sparing maintenance immunosuppression regimen can be successfully employed in paediatric OHT, and that significant catch-up growth can be achieved postoperatively.
Collapse
Affiliation(s)
- J Au
- Cardiopulmonary Transplant Unit, Freeman Hospital, Newcastle upon Tyne
| | | | | | | | | | | | | |
Collapse
|