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Raissadati A, Pihkala J, Jahnukainen T, Jokinen E, Jalanko H, Sairanen H. Late outcome after paediatric heart transplantation in Finland. Interact Cardiovasc Thorac Surg 2016; 23:18-25. [PMID: 27034098 DOI: 10.1093/icvts/ivw086] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 03/04/2016] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES We studied the long-term survival and rejection episodes of paediatric heart transplant recipients. METHODS We included all paediatric patients (≤18 years) who underwent heart transplantation during 1991-2014 in Finland. Data were obtained retrospectively from a paediatric cardiac surgery database. Patient status was received from the Finnish population registry. All patients underwent yearly routine postoperative endomyocardial biopsies and coronary angiographies. RESULTS Between 1991 and 2014, 68 heart transplantations were performed. The early mortality (<30 days after surgery) rate was 10% and follow-up coverage was 100%. The 10- and 15-year survival rates for all patients were 68% (95% confidence internal, CI, 56-80%) and 65% (95% CI 53-78%), respectively, including early mortality. The 1-year survival rate was 100% when excluding early operative mortality. Indications for heart transplantation were cardiomyopathy in 57% and cardiac malformations in 43% of patients, with similar long-term survival between the groups. During 23 years of follow-up, 43 patients (70%) had at least one rejection episode and 17 patients (29%) at least a grade 1 coronary artery vasculopathy finding. Patients with early rejection episodes (<3 months) had a higher incidence of late rejection episodes (P = 0.025). Older age at operation was a significant risk factor for the development of coronary artery vasculopathy (hazard ratio 1.1, 95% CI 1.0-1.3, P = 0.012). CONCLUSIONS First-year survival was excellent. Asymptomatic rejection episodes were common among patients. Early rejection episodes are a risk factor for late rejection episodes and show a trend towards an increased risk of late death. Coronary artery vasculopathy remains a major challenge for late graft survival.
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Affiliation(s)
- Alireza Raissadati
- Departments of Pediatric Thoracic and Transplantation Surgery, Pediatric Cardiology and Pediatric Nephrology and Transplantation, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jaana Pihkala
- Departments of Pediatric Thoracic and Transplantation Surgery, Pediatric Cardiology and Pediatric Nephrology and Transplantation, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Timo Jahnukainen
- Departments of Pediatric Thoracic and Transplantation Surgery, Pediatric Cardiology and Pediatric Nephrology and Transplantation, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Eero Jokinen
- Departments of Pediatric Thoracic and Transplantation Surgery, Pediatric Cardiology and Pediatric Nephrology and Transplantation, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Hannu Jalanko
- Departments of Pediatric Thoracic and Transplantation Surgery, Pediatric Cardiology and Pediatric Nephrology and Transplantation, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Heikki Sairanen
- Departments of Pediatric Thoracic and Transplantation Surgery, Pediatric Cardiology and Pediatric Nephrology and Transplantation, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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2
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Reinhartz O, Maeda K, Reitz BA, Bernstein D, Luikart H, Rosenthal DN, Hollander SA. Changes in Risk Profile Over Time in the Population of a Pediatric Heart Transplant Program. Ann Thorac Surg 2015; 100:989-94; discussion 995. [PMID: 26228604 DOI: 10.1016/j.athoracsur.2015.05.111] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 04/29/2015] [Accepted: 05/04/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Single-center data on pediatric heart transplantation spanning long time frames is sparse. We attempted to analyze how risk profile and pediatric heart transplant survival outcomes at a large center changed over time. METHODS We divided 320 pediatric heart transplants done at Stanford University between 1974 and 2014 into three groups by era: the first 20 years (95 transplants), the subsequent 10 years (87 transplants), and the most recent 10 years (138 transplants). Differences in age at transplant, indication, mechanical support, and survival were analyzed. RESULTS Follow-up was 100% complete. Average age at time of transplantation was 10.4 years, 11.9 years, and 5.6 years in eras 1, 2, and 3, respectively. The percentage of infants who received transplants by era was 21%, 7%, and 18%, respectively. The indication of end-stage congenital heart disease vs cardiomyopathy was 24%, 22%, and 49%, respectively. Only 1 patient (1%) was on mechanical support at transplant in era 1 compared with 15% in era 2 and 30% in era 3. Overall survival was 72% at 5 years and 57% at 10 years. Long-term survival increased significantly with each subsequent era. Patients with cardiomyopathy generally had a survival advantage over those with congenital heart disease. CONCLUSIONS The risk profile of pediatric transplant patients in our institution has increased over time. In the last 10 years, median age has decreased and ventricular assist device support has increased dramatically. Transplantation for end-stage congenital heart disease is increasingly common. Despite this, long-term survival has significantly and consistently improved.
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Affiliation(s)
- Olaf Reinhartz
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California.
| | - Katsuhide Maeda
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
| | - Bruce A Reitz
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
| | - Daniel Bernstein
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Stanford, California
| | - Helen Luikart
- Department of Cardiology, Stanford University, Stanford, California
| | - Daniel N Rosenthal
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Stanford, California
| | - Seth A Hollander
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Stanford, California
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3
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Lunze FI, Colan SD, Gauvreau K, Chen MH, Perez-Atayde AR, Blume ED, Singh TP. Cardiac Allograft Function During the First Year after Transplantation in Rejection-Free Children and Young Adults. Circ Cardiovasc Imaging 2012; 5:756-64. [DOI: 10.1161/circimaging.112.976613] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Allograft dysfunction is a common finding early after heart transplant (HT). We sought to assess the recovery of left (LV) and right ventricular (RV) function during the first year after HT in children and young adults using pulsed-wave tissue Doppler imaging.
Methods and Results—
We analyzed serially performed echocardiography in 44 pediatric HT recipients (median age: 7.3 years at HT) who remained rejection-free during the first year post-transplant. Age-based normative values for systolic (
S
′), early-diastolic (
E
′), and late-diastolic (
A
′) velocities obtained using pulsed-wave tissue Doppler imaging in 380 healthy children were used to transform patient data into
z
scores. Pulsed-wave tissue Doppler imaging studies ≤10 days post-HT demonstrated biventricular systolic and diastolic dysfunction with most prominent impairment in RV systolic function (
S
′
z
score −2.7±0.8), RV early-diastolic filling (
E
′
z
score −2.3±1.1), and LV early-diastolic filling (
E
′
z
score −2.3±1.1). LV systolic function (
S
′
z
score) and late-diastolic filling (
A
′
z
score) improved to normal in 11 to 30 days, LV early-diastolic filling (
E
′
z
score) in 4 to 6 months, and RV early-diastolic filling in 6 to 9 months (
P
<0.001 for all on longitudinal analysis). However, RV systolic function (RV
S
′
z
score −1.2±1.1) remained impaired 1-year post-transplant. Analysis of serial cardiac catheterization studies showed that RV and LV filling pressures were elevated early post-HT and declined gradually during the first year post-transplant.
Conclusions—
Pediatric HT recipients have biventricular dysfunction using pulsed-wave tissue Doppler imaging early after HT with most significant impairment in RV systolic function and RV and LV early-diastolic filling. Although other aspects of LV and RV function normalize in 6 to 9 months, RV systolic function remains abnormal 1 year-post-transplant.
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Affiliation(s)
- Fatima I. Lunze
- From the Departments of Cardiology (F.I.L., S.D.C., K.G., M.H.C., E.D.B., T.P.S.), Medicine (M.H.C.), and Pathology (A.R.P-A.), Boston Children’s Hospital, Boston, MA; Departments of Pediatrics (S.D.C., E.D.B., T.P.S.), and Pathology (A.R.P-A.), Harvard Medical School, Boston, MA; and Department of Biostatistics, Harvard School of Public Health (KG), Boston, MA
| | - Steven D. Colan
- From the Departments of Cardiology (F.I.L., S.D.C., K.G., M.H.C., E.D.B., T.P.S.), Medicine (M.H.C.), and Pathology (A.R.P-A.), Boston Children’s Hospital, Boston, MA; Departments of Pediatrics (S.D.C., E.D.B., T.P.S.), and Pathology (A.R.P-A.), Harvard Medical School, Boston, MA; and Department of Biostatistics, Harvard School of Public Health (KG), Boston, MA
| | - Kimberlee Gauvreau
- From the Departments of Cardiology (F.I.L., S.D.C., K.G., M.H.C., E.D.B., T.P.S.), Medicine (M.H.C.), and Pathology (A.R.P-A.), Boston Children’s Hospital, Boston, MA; Departments of Pediatrics (S.D.C., E.D.B., T.P.S.), and Pathology (A.R.P-A.), Harvard Medical School, Boston, MA; and Department of Biostatistics, Harvard School of Public Health (KG), Boston, MA
| | - Ming Hui Chen
- From the Departments of Cardiology (F.I.L., S.D.C., K.G., M.H.C., E.D.B., T.P.S.), Medicine (M.H.C.), and Pathology (A.R.P-A.), Boston Children’s Hospital, Boston, MA; Departments of Pediatrics (S.D.C., E.D.B., T.P.S.), and Pathology (A.R.P-A.), Harvard Medical School, Boston, MA; and Department of Biostatistics, Harvard School of Public Health (KG), Boston, MA
| | - Antonio R. Perez-Atayde
- From the Departments of Cardiology (F.I.L., S.D.C., K.G., M.H.C., E.D.B., T.P.S.), Medicine (M.H.C.), and Pathology (A.R.P-A.), Boston Children’s Hospital, Boston, MA; Departments of Pediatrics (S.D.C., E.D.B., T.P.S.), and Pathology (A.R.P-A.), Harvard Medical School, Boston, MA; and Department of Biostatistics, Harvard School of Public Health (KG), Boston, MA
| | - Elizabeth D. Blume
- From the Departments of Cardiology (F.I.L., S.D.C., K.G., M.H.C., E.D.B., T.P.S.), Medicine (M.H.C.), and Pathology (A.R.P-A.), Boston Children’s Hospital, Boston, MA; Departments of Pediatrics (S.D.C., E.D.B., T.P.S.), and Pathology (A.R.P-A.), Harvard Medical School, Boston, MA; and Department of Biostatistics, Harvard School of Public Health (KG), Boston, MA
| | - Tajinder P. Singh
- From the Departments of Cardiology (F.I.L., S.D.C., K.G., M.H.C., E.D.B., T.P.S.), Medicine (M.H.C.), and Pathology (A.R.P-A.), Boston Children’s Hospital, Boston, MA; Departments of Pediatrics (S.D.C., E.D.B., T.P.S.), and Pathology (A.R.P-A.), Harvard Medical School, Boston, MA; and Department of Biostatistics, Harvard School of Public Health (KG), Boston, MA
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Total donor ischemic time: relationship to early hemodynamics and intensive care morbidity in pediatric cardiac transplant recipients. Pediatr Crit Care Med 2011; 12:660-6. [PMID: 21478795 DOI: 10.1097/pcc.0b013e3182192a84] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Single-center studies have failed to link modest increases in total donor ischemic time to mortality after pediatric orthotopic heart transplant. We aimed to investigate whether prolonged total donor ischemic time is linked to pediatric intensive care morbidity after orthotopic heart transplant. DESIGN Retrospective cohort review. SETTING Tertiary pediatric transplant center in the United Kingdom. PATIENTS Ninety-three pediatric orthotopic heart transplants between 2002 and 2006. METHODS Total donor ischemic time was investigated for association with early post-orthotopic heart transplant hemodynamics and intensive care unit morbidities. RESULTS Of 43 males and 50 females with median age 7.2 (interquartile range 2.2, 13.0) yrs, 62 (68%) had dilated cardiomyopathy, 20 (22%) had congenital heart disease, and nine (10%) had restrictive cardiomyopathy. The mean total donor ischemic time was 225.9 (sd 65.6) mins. In the first 24 hrs after orthotopic heart transplant, age-adjusted mean arterial blood pressure increased (p < .001), mean pulmonary arterial pressure fell (p = .012), but central venous pressure (p = .58) and left atrial pressure (p = .20) were unchanged. After adjustment for age, primary diagnosis, pre-orthotopic heart transplant mechanical support, and marginal donor factors, longer total donor ischemic time was significantly associated with lower mean arterial blood pressure (p < .001) in the first 24 hrs after orthotopic heart transplant, longer post-orthotopic heart transplant mechanical ventilation (p = .03), longer post-orthotopic heart transplant stay in the intensive care unit (p = .004), and longer post-orthotopic heart transplant stay in hospital (p = .02). Total donor ischemic time was not related to levels of mean pulmonary arterial pressure (p = .62), left atrial pressure (p = .38), or central venous pressure (p = .76) early after orthotopic heart transplant. CONCLUSIONS Prolonged total donor ischemic time has an adverse effect on the donor organ, contributing to lower mean arterial blood pressure, as well as more prolonged ventilation and intensive care unit and hospital stays post-orthotopic heart transplant, reflecting increased morbidity.
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