1
|
John MM, Zinyandu T, Rosenblum JM, Shashidharan S, Chai PJ, Shaw FR. Neonatal heart transplantation in the United States: Trends and outcomes. Pediatr Transplant 2024; 28:e14792. [PMID: 38808741 DOI: 10.1111/petr.14792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 05/01/2024] [Accepted: 05/14/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND Heart transplantation in the neonatal period is associated with excellent survival. However, outcomes data are scant and have been obtained primarily from two single-center reports within the United States. We sought to analyze the outcomes of all neonatal heart transplants performed in the United States using the United Network for Organ Sharing (UNOS) dataset. METHODS The UNOS dataset was queried for patients who underwent infant heart transplantation from 1987 to 2021. Patients were divided into two groups based on age - neonates (<=31 days), and older infants (32 days-365 days). Demographic and clinical characteristics were analyzed and compared, along with follow up survival data. RESULTS Overall, 474 newborns have undergone heart transplantation in the United States since 1987. Freedom from death or re-transplantation for neonates was 63.5%, 58.8% and 51.6% at 5, 10, and 20 years, respectively. Patients in the newborn group had lower unadjusted survival compared to older infants (p < .001), but conditional 1-year survival was higher in neonates (p = .03). On multivariable analysis, there was no significant difference in survival between the two age groups (p = .43). Black race, congenital heart disease diagnosis, earlier surgical era, and preoperative mechanical circulatory support use were associated with lower survival among infant transplants (p < .05). CONCLUSIONS Neonatal heart transplantation is associated with favorable long-term clinical outcomes. Neonates do not have a significant survival advantage over older infants. Widespread applicability is limited by the small number of available donors. Efforts to expand the donor pool to include non-standard donor populations ought to be considered.
Collapse
Affiliation(s)
- Mohan M John
- Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta/Emory University School of Medicine, Atlanta, Georgia, USA
| | - Tawanda Zinyandu
- Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta/Emory University School of Medicine, Atlanta, Georgia, USA
| | - Joshua M Rosenblum
- Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta/Emory University School of Medicine, Atlanta, Georgia, USA
| | - Subhadra Shashidharan
- Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta/Emory University School of Medicine, Atlanta, Georgia, USA
| | - Paul J Chai
- Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta/Emory University School of Medicine, Atlanta, Georgia, USA
| | - Fawwaz R Shaw
- Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta/Emory University School of Medicine, Atlanta, Georgia, USA
| |
Collapse
|
2
|
Medina CK, Aykut B, Kang L, McVadon D, Overbey DM, Helke KL, Taylor CL, Fitzgerald DC, Hassid M, Braxton AM, Miller SG, Mealer C, Ho CS, Whitworth KM, Prather RS, Moya-Mendez ME, Jeffs S, Parker LE, Turek JW, Rajab TK. Surgical Protocol for Partial Heart Transplantation in Growing Piglets. World J Pediatr Congenit Heart Surg 2024:21501351241245115. [PMID: 38780414 DOI: 10.1177/21501351241245115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Partial heart transplantation is a new approach to deliver growing heart valve implants. Partial heart transplants differ from heart transplants because only the part of the heart containing the necessary heart valve is transplanted. This allows partial heart transplants to grow, similar to the valves in heart transplants. However, the transplant biology of partial heart transplantation remains unexplored. This is a critical barrier to progress of the field. Without knowledge about the specific transplant biology of partial heart transplantation, children with partial heart transplants are empirically treated like children with heart transplants because the valves in heart transplants are known to grow. In order to progress the field, an animal model for partial heart transplantation is necessary. Here, we contribute our surgical protocol for partial heart transplantation in growing piglets. All aspects of partial heart transplantation, including the donor procedure, the recipient procedure, and recipient perioperative care are described in detail. There are important nuances in the conduct of virtually all aspects of open heart surgery that differs in piglets from humans. Our surgical protocol, which is based on our experience with 34 piglets, will allow other investigators to leverage our experience to seek fundamental knowledge about the nature of partial heart transplants. This is significant because the partial heart transplant model in piglets is complex and very resource intensive.
Collapse
Affiliation(s)
- Cathlyn K Medina
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Berk Aykut
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Lillian Kang
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Deani McVadon
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Douglas M Overbey
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Kristi L Helke
- Department of Comparative Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Carolyn L Taylor
- Department of Comparative Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - David C Fitzgerald
- Division of Cardiovascular Perfusion, Department of Clinical Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Marc Hassid
- Division of Pediatric Cardiac Anesthesia, Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Alicia M Braxton
- Department of Comparative Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Stephen G Miller
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Corey Mealer
- Department of Comparative Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Chak-Sum Ho
- Gift of Hope Organ and Tissue Donor Network, Chicago, IL, USA
| | - Kristin M Whitworth
- National Swine Resource and Research Center, University of Missouri, MO, USA
| | - Randall S Prather
- National Swine Resource and Research Center, University of Missouri, MO, USA
| | | | - Sydney Jeffs
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Lauren E Parker
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Joseph W Turek
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | | |
Collapse
|
3
|
Rajab TK. Partial heart transplantation: Growing heart valve implants for children. Artif Organs 2024; 48:326-335. [PMID: 37849378 PMCID: PMC10960715 DOI: 10.1111/aor.14664] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 09/11/2023] [Accepted: 10/02/2023] [Indexed: 10/19/2023]
Abstract
Heart valves serve a vital hemodynamic function to ensure unidirectional blood flow. Additionally, native heart valves serve biological functions such as growth and self-repair. Heart valve implants mimic the hemodynamic function of native heart valves, but are unable to fulfill their biological functions. We developed partial heart transplantation to deliver heart valve implants that fulfill all functions of native heart valves. This is particularly advantageous for children, who require growing heart valve implants. This invited review outlines the past, present and future of partial heart transplantation.
Collapse
Affiliation(s)
- Taufiek Konrad Rajab
- Division of Pediatric Cardiovascular Surgery, Arkansas Children's Hospital, Little Rock, Arkansas, USA
| |
Collapse
|
4
|
Overbey DM, Rajab TK, Turek JW. Partial Heart Transplantation - How to Change the System. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2024; 27:100-105. [PMID: 38522865 DOI: 10.1053/j.pcsu.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 01/03/2024] [Accepted: 01/12/2024] [Indexed: 03/26/2024]
Abstract
Partial heart transplantation is the first clinically successful approach to deliver growing heart valve implants. To date, 13 clinical partial heart transplants have been performed. However, turning partial heart transplantation into a routine procedure that is available to all children who would benefit from growing heart valve implants poses formidable logistical challenges. Firstly, a supply for partial heart transplant donor grafts needs to be developed. This challenge is complicated by the scarcity of donor organs. Importantly, the donor pools for orthotopic heart transplants, partial heart transplants and cadaver homografts overlap. Secondly, partial heart transplants need to be allocated. Factors relevant for equitable allocation include the indication, anatomical fit, recipient clinical status and time on the wait list. Finally, partial heart transplantation will require regulation and oversight, which only recently has been undertaken by the Food and Drug Administration, which regulates human cellular and tissue-based products. Overcoming these challenges will require a change in the system. Once this is achieved, partial heart transplantation could open new horizons for children who require growing tissue implants.
Collapse
Affiliation(s)
- Douglas M Overbey
- Congenital Heart Surgery Research and Training Laboratory, Duke University, Durham, North Carolina.; Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Taufiek K Rajab
- Medical University of South Carolina, Charleston, South Carolina.; Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Joseph W Turek
- Congenital Heart Surgery Research and Training Laboratory, Duke University, Durham, North Carolina.; Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina..
| |
Collapse
|
5
|
Turek JW, Kang L, Overbey DM, Carboni MP, Rajab TK. Partial Heart Transplant in a Neonate With Irreparable Truncal Valve Dysfunction. JAMA 2024; 331:60-64. [PMID: 38165407 PMCID: PMC10762570 DOI: 10.1001/jama.2023.23823] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/24/2023] [Indexed: 01/03/2024]
Abstract
Importance The treatment of neonates with irreparable heart valve dysfunction remains an unsolved problem because there are no heart valve implants that grow. Therefore, neonates with heart valve implants are committed to recurrent implant exchanges until an adult-sized valve can fit. Objective To deliver the first heart valve implant that grows. Design, Setting, and Participants Case report from a pediatric referral center, with follow-up for more than 1 year. Participants were a recipient neonate with persistent truncus arteriosus and irreparable truncal valve dysfunction and a donor neonate with hypoxic-ischemic brain injury. Intervention First-in-human transplant of the part of the heart containing the aortic and pulmonary valves. Main Outcomes and Measures Transplanted valve growth and hemodynamic function. Results Echocardiography demonstrated adaptive growth and excellent hemodynamic function of the partial heart transplant valves. Conclusions and Relevance In this child, partial heart transplant delivered growing heart valve implants with a good outcome at age 1 year. Partial heart transplants may improve the treatment of neonates with irreparable heart valve dysfunction.
Collapse
Affiliation(s)
| | - Lillian Kang
- Duke University Medical Center, Durham, North Carolina
| | | | | | | |
Collapse
|
6
|
Rajab TK, Goerlich CE, Forbess JM, Griffith BP, Mohiuddin MM. Partial heart xenotransplantation: A research protocol in non-human primates. Artif Organs 2023; 47:1262-1266. [PMID: 37334835 DOI: 10.1111/aor.14546] [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: 02/10/2023] [Accepted: 04/06/2023] [Indexed: 06/21/2023]
Abstract
Partial heart transplantation is a new type of transplant that delivers growing heart valve replacements for babies. Partial heart transplantation differs from orthotopic heart transplantation because only the part of the heart containing the heart valve is transplanted. It also differs from homograft valve replacement because viability of the graft is preserved by tissue matching, minimizing donor ischemia times, and recipient immunosuppression. This preserves partial heart transplant viability and allows the grafts to fulfill biological functions such as growth and self-repair. These advantages over conventional heart valve prostheses are balanced by similar disadvantages as other organ transplants, most importantly limitations in donor graft availability. Prodigious progress in xenotransplantation promises to solve this problem by providing an unlimited source of donor grafts. In order to study partial heart xenotransplantation, a suitable large animal model is important. Here we describe our research protocol for partial heart xenotransplantation in nonhuman primates.
Collapse
Affiliation(s)
- Taufiek Konrad Rajab
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Corbin E Goerlich
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Joseph M Forbess
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Bartley P Griffith
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Muhammad M Mohiuddin
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
7
|
Rajab TK, Kang L, Hayden K, Andersen ND, Turek JW. New operations for truncus arteriosus repair using partial heart transplantation: Exploring the surgical design space with 3-dimensional printed heart models. JTCVS Tech 2023; 18:91-96. [PMID: 37096099 PMCID: PMC10122159 DOI: 10.1016/j.xjtc.2023.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/18/2023] [Accepted: 02/07/2023] [Indexed: 02/16/2023] Open
Affiliation(s)
- T. Konrad Rajab
- Section of Pediatric Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - Lillian Kang
- Duke Children's Pediatric & Congenital Heart Center, Duke Children's Hospital, Durham, NC
| | - Kaila Hayden
- Section of Pediatric Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - Nicholas D. Andersen
- Duke Children's Pediatric & Congenital Heart Center, Duke Children's Hospital, Durham, NC
| | - Joseph W. Turek
- Duke Children's Pediatric & Congenital Heart Center, Duke Children's Hospital, Durham, NC
| |
Collapse
|
8
|
Konsek H, Sherard C, Bisbee C, Kang L, Turek JW, Rajab TK. Growing Heart Valve Implants for Children. J Cardiovasc Dev Dis 2023; 10:jcdd10040148. [PMID: 37103027 PMCID: PMC10143004 DOI: 10.3390/jcdd10040148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/28/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023] Open
Abstract
The current standard of care for pediatric patients with unrepairable congenital valvular disease is a heart valve implant. However, current heart valve implants are unable to accommodate the somatic growth of the recipient, preventing long-term clinical success in these patients. Therefore, there is an urgent need for a growing heart valve implant for children. This article reviews recent studies investigating tissue-engineered heart valves and partial heart transplantation as potential growing heart valve implants in large animal and clinical translational research. In vitro and in situ designs of tissue engineered heart valves are discussed, as well as the barriers to clinical translation.
Collapse
|
9
|
Survival After Intervention for Single-Ventricle Heart Disease Over 15 Years at a Single Institution. Ann Thorac Surg 2022; 114:2303-2312. [PMID: 35430225 DOI: 10.1016/j.athoracsur.2022.03.060] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 02/23/2022] [Accepted: 03/22/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Children with single-ventricle (SV) heart disease possess a spectrum of heart malformations, yet progress through similar hemodynamic states, suggesting differences in outcomes are related to fundamental morphologic differences, patient characteristics, or procedural pathways. We sought to provide a holistic overview of survival after intervention for SV heart disease at our institution. METHODS SV heart disease was defined as patients born with a hypoplastic or dysfunctional ventricle with uncertain or unacceptable candidacy for a 2-ventricle circulation. Patients were stratified into 8 diagnostic groups and 11 procedural categories based on the initial interventional procedure. RESULTS Between 2005 and 2020, 381 patients born with SV heart disease underwent intervention at our institution. Ten-year survival was highest for patients with double inlet left ventricle (89% ± 7%) and lowest for patients with hypoplastic left heart syndrome (55% ± 5%). Initial palliation with less invasive procedures, such as ductal stent (4-year: 100%) or pulmonary artery banding (10-year: 95% ± 5%), demonstrated superior survival compared with more invasive procedures such as the Norwood procedure (10-year: 59% ± 4%). Survival of patients who achieved a biventricular circulation was superior to patients who remained with SV physiology (10-year: 87% ± 5% vs 63% ± 3%, P = .04). In a multivariable analysis, chromosomal/syndromic abnormality, lower weight, hybrid Norwood procedure, nonleft ventricular dominance, and earlier year of operation were risk factors for death. CONCLUSIONS Survival differences in patients with SV heart disease were related primarily to underlying cardiac anatomy, patient characteristics, and procedural complexity. Left ventricular dominance, more recent intervention, and attainment of a 2-ventricle circulation were associated with improved survival.
Collapse
|
10
|
Hope KD, John MM, Adachi I. Commentary: The fate of pediatric cardiac palliations: Beyond the convergence. J Thorac Cardiovasc Surg 2021; 162:1373-1374. [PMID: 33965217 DOI: 10.1016/j.jtcvs.2021.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 04/03/2021] [Accepted: 04/06/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Kyle D Hope
- Lille Frank Abercrombie Section of Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Mohan M John
- Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Iki Adachi
- Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex.
| |
Collapse
|
11
|
Overbey DM, Lodge AJ. Commentary: Neonatal heart transplant: A good option in a bad situation. J Thorac Cardiovasc Surg 2021; 162:1371-1372. [PMID: 33712240 DOI: 10.1016/j.jtcvs.2021.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/02/2021] [Accepted: 02/03/2021] [Indexed: 10/22/2022]
Affiliation(s)
- Douglas M Overbey
- Cardiothoracic Surgery Residency Program, Durham, NC; Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Andrew J Lodge
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
| |
Collapse
|
12
|
Bichell DP. Commentary: The importance and treachery of patient selection for neonatal heart transplant. J Thorac Cardiovasc Surg 2021; 162:1370-1371. [PMID: 33726902 DOI: 10.1016/j.jtcvs.2021.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 02/01/2021] [Accepted: 02/01/2021] [Indexed: 10/22/2022]
Affiliation(s)
- David P Bichell
- Department of Cardiac Surgery, Monroe Carell Jr Children's Hospital, Vanderbilt University Medical Center, Nashville, Tenn.
| |
Collapse
|
13
|
Eckhauser A. Commentary: Neonatal heart transplant: Conservation status-critically endangered. J Thorac Cardiovasc Surg 2021; 162:1369. [PMID: 33612301 DOI: 10.1016/j.jtcvs.2021.01.098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 01/24/2021] [Accepted: 01/25/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Aaron Eckhauser
- Pediatric Cardiothoracic Surgery, Division of Cardiothoracic Surgery, Department of Surgery, University of Utah, Salt Lake City, Utah.
| |
Collapse
|