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Márquez-González H, Hernández-Vásquez JG, Del Valle-Lom M, Yáñez-Gutiérrez L, Klünder-Klünder M, Almeida-Gutiérrez E, Koretzky SG. Failures of the Fontan System in Univentricular Hearts and Mortality Risk in Heart Transplantation: A Systematic Review and Meta-Analysis. Life (Basel) 2021; 11:1363. [PMID: 34947894 PMCID: PMC8709145 DOI: 10.3390/life11121363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 11/12/2021] [Accepted: 11/13/2021] [Indexed: 02/07/2023] Open
Abstract
The Fontan procedure (FP) is the standard surgical treatment for Univentricular heart diseases. Over time, the Fontan system fails, leading to pathologies such as protein-losing enteropathy (PLE), plastic bronchitis (PB), and heart failure (HF). FP should be considered as a transitional step to the final treatment: heart transplantation (HT). This systematic review and meta-analysis aims to establish the risk of death following HT according to the presence of FP complications. There was a total of 691 transplanted patients in the 18 articles, immediate survival 88% (n = 448), survival from 1 to 5 years of 78% (n = 427) and survival from 5.1 to 10 years of 69% (n = 208), >10 years 61% (n = 109). The relative risk (RR) was 1.12 for PLE (95% confidence interval [CI] = 0.89-1.40, p = 0.34), 1.03 for HF (0.7-1.51, p = 0.88), 0.70 for Arrhythmias (0.39-1.24, p = 0.22), 0.46 for PB (0.08-2.72, p = 0.39), and 5.81 for CKD (1.70-19.88, p = 0.005). In patients with two or more failures, the RR was 1.94 (0.99-3.81, p = 0.05). After FP, the risk of death after HT is associated with CKD and with the presence of two or more failures.
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Affiliation(s)
- Horacio Márquez-González
- Department of Clinical Research, Federico Gómez Children’s Hospital, Mexico City 06720, Mexico; (H.M.-G.); (J.G.H.-V.); (M.D.V.-L.); (M.K.-K.)
- Centro Médico Nacional Siglo XXI, IMSS, Department Congenital Heart Diseases, Mexico City 06720, Mexico; (L.Y.-G.); (E.A.-G.)
| | - Jose Gustavo Hernández-Vásquez
- Department of Clinical Research, Federico Gómez Children’s Hospital, Mexico City 06720, Mexico; (H.M.-G.); (J.G.H.-V.); (M.D.V.-L.); (M.K.-K.)
| | - Montserrat Del Valle-Lom
- Department of Clinical Research, Federico Gómez Children’s Hospital, Mexico City 06720, Mexico; (H.M.-G.); (J.G.H.-V.); (M.D.V.-L.); (M.K.-K.)
| | - Lucelli Yáñez-Gutiérrez
- Centro Médico Nacional Siglo XXI, IMSS, Department Congenital Heart Diseases, Mexico City 06720, Mexico; (L.Y.-G.); (E.A.-G.)
| | - Miguel Klünder-Klünder
- Department of Clinical Research, Federico Gómez Children’s Hospital, Mexico City 06720, Mexico; (H.M.-G.); (J.G.H.-V.); (M.D.V.-L.); (M.K.-K.)
| | - Eduardo Almeida-Gutiérrez
- Centro Médico Nacional Siglo XXI, IMSS, Department Congenital Heart Diseases, Mexico City 06720, Mexico; (L.Y.-G.); (E.A.-G.)
| | - Solange Gabriela Koretzky
- Department of Clinical Research, Nacional de Cardiología “Ignacio Chávez”, Mexico City 14080, Mexico
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Jeung MS, Kim MJ, Huh J, Kang IS, Kim GB, Yu JJ, Song J. The Waiting List Mortality of Pediatric Heart Transplantation Candidates in Korea before the Pediatric Ventricular Assist Device Era. J Korean Med Sci 2021; 36:e283. [PMID: 34783215 PMCID: PMC8593407 DOI: 10.3346/jkms.2021.36.e283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 09/22/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Despite advancements in heart transplantation for pediatric patients in Korea, the waiting list mortality has not been reported. Therefore, we investigated the waiting list mortality rate and factors associated with patient mortality. METHODS We reviewed the medical records of pediatric patients who were registered for heart transplantation at three major hospitals in Korea from January 2000 to January 2020. All patients who died while waiting for heart transplantation were investigated, and we identified the waiting list mortality rate, causes of mortality and median survival periods depending on the variable risk factors. RESULTS A total of 145 patients received heart transplantations at the three institutions we surveyed, and the waiting list mortality rate was 26%. The most common underlying diseases were cardiomyopathy (66.7%) and congenital heart disease (30.3%). The leading causes that contributed to death were heart failure (36.3%), multi-organ failure (27.2%), and complications associated with extracorporeal membrane oxygenation (ECMO) (25.7%). The median survival period was 63 days. ECMO was applied in 30 patients. The different waiting list mortality percentages according to age, cardiac diagnosis, use of ECMO, and initial Korean Network of Organ Sharing (KONOS) level were determined using univariate analysis, but age was the only significant factor associated with waiting list mortality based on a multivariate analysis. CONCLUSION The waiting list mortality of pediatric heart transplantation candidates was confirmed to be considerably high, and age, underlying disease, the application of ECMO, and the initial KONOS level were the factors that influenced the survival period.
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Affiliation(s)
- Min Sub Jeung
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Mi Jin Kim
- Department of Pediatrics, Asan Medical Center, Seoul, Korea
| | - June Huh
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - I-Seok Kang
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gi Beom Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Jeong Jin Yu
- Department of Pediatrics, Asan Medical Center, Seoul, Korea
| | - Jinyoung Song
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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3
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Edelson JB, Huang Y, Griffis H, Huang J, Mascio CE, Chen JM, Maeda K, Burstein DS, Wittlieb-Weber C, Lin KY, O'Connor MJ, Rossano JW. The influence of mechanical Circulatory support on post-transplant outcomes in pediatric patients: A multicenter study from the International Society for Heart and Lung Transplantation (ISHLT) Registry. J Heart Lung Transplant 2021; 40:1443-1453. [PMID: 34253457 DOI: 10.1016/j.healun.2021.06.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 05/12/2021] [Accepted: 06/08/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Mechanical circulatory support (MCS) is increasingly being used as a bridge to transplant in pediatric patients. We compare outcomes in pediatric patients bridged to transplant with MCS from an international cohort. METHODS This retrospective cohort study of heart-transplant patients reported to the International Society for Heart and Lung Transplantation (ISHLT) registry from 2005-2017 includes 5,095 patients <18 years. Pretransplant MCS exposure and anatomic diagnosis were derived. Outcomes included mortality, renal failure, and stroke. RESULTS 26% of patients received MCS prior to transplant: 240 (4.7%) on extracorporeal membrane oxygenation (ECMO), 1,030 (20.2%) on ventricular assist device (VAD), and 54 (1%) both. 29% of patients were <1 year, and 43.8% had congenital heart disease (CHD). After adjusting for clinical characteristics, compared to no-MCS and VAD, ECMO had higher mortality during their transplant hospitalization [OR 3.97 & 2.55; 95% CI 2.43-6.49 & 1.42-4.60] while VAD mortality was similar [OR 1.55; CI 0.99-2.45]. Outcomes of ECMO+VAD were similar to ECMO alone, including increased mortality during transplant hospitalization compared to no-MCS [OR 4.74; CI 1.81-12.36]. Patients with CHD on ECMO had increased 1 year, and 10 year mortality [HR 2.36; CI 1.65-3.39], [HR 1.82; CI 1.33-2.49]; there was no difference in survival in dilated cardiomyopathy (DCM) patients based on pretransplant MCS status. CONCLUSION Survival in CHD and DCM is similar in patients with no MCS or VAD prior to transplant, while pretransplant ECMO use is strongly associated with mortality after transplant particularly in children with CHD. In children with DCM, long term survival was equivalent regardless of MCS status.
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Affiliation(s)
- J B Edelson
- Division of Cardiology, Cardiac Center, the Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania; Leonard Davis Institute for Healthcare Economics, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Y Huang
- Department of Biomedical Health Informatics, Data Science and Biostatistics Unit, the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - H Griffis
- Department of Biomedical Health Informatics, Data Science and Biostatistics Unit, the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - J Huang
- Department of Biomedical Health Informatics, Data Science and Biostatistics Unit, the Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - C E Mascio
- Division of Cardiothoracic Surgery, Cardiac Center, the Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - J M Chen
- Division of Cardiothoracic Surgery, Cardiac Center, the Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - K Maeda
- Division of Cardiothoracic Surgery, Cardiac Center, the Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - D S Burstein
- Division of Cardiology, Cardiac Center, the Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - C Wittlieb-Weber
- Division of Cardiology, Cardiac Center, the Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - K Y Lin
- Division of Cardiology, Cardiac Center, the Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - M J O'Connor
- Division of Cardiology, Cardiac Center, the Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - J W Rossano
- Division of Cardiology, Cardiac Center, the Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania; Leonard Davis Institute for Healthcare Economics, University of Pennsylvania, Philadelphia, Pennsylvania
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4
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The difficult to transplant patient: Challenges and opportunities. PROGRESS IN PEDIATRIC CARDIOLOGY 2019. [DOI: 10.1016/j.ppedcard.2019.101131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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5
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Sims T, Tumin D, Hayes D, Tobias JD. Age-Dependent Impact of Pre-Transplant Intensive Care Unit Stay on Mortality in Heart Transplant Recipients. Cardiol Res 2019; 10:157-164. [PMID: 31236178 PMCID: PMC6575112 DOI: 10.14740/cr870] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 05/30/2019] [Indexed: 11/19/2022] Open
Abstract
Background Heart transplantation (HTx) is a treatment option for refractory end-stage heart failure. Severe illness requiring pre-transplant intensive care unit (ICU) stay may be a risk factor for diminished post-transplant survival, but this association is surprisingly inconsistent in recent studies. To clarify the significance of ICU stay as a risk factor for heart transplant outcomes, we aimed to define if patient age was a factor in which ICU stay was predictive of survival after HTx. Methods De-identified data were obtained on isolated first-time HTx performed during the years 2006 - 2015 from the UNOS Registry. Nine age groups were defined. The primary outcome was 1-year post-transplant mortality. Cox proportional hazard regression estimated unadjusted and adjusted hazard ratio (HR) associated with pre-transplant ICU stay in each age group. Results The analysis included 19,508 patients (9% deceased within 1 year). In the overall cohort, pre-transplant ICU stay was associated with increased hazard of 1-year mortality (HR = 1.3; 95% confidence interval (CI): 1.2 - 1.4; P < 0.001); but further univariate analysis showed a greater hazard of 1-year mortality associated with ICU stay in infants (HR = 2.2; 95% CI: 1.5 - 3.2; P < 0.001). However, the adjusted analysis found that adults ages 40 - 49 had the highest statistically significant hazard of 1-year mortality (HR = 1.5; 95% CI: 1.1 - 2.1; P = 0.011). Conclusions Our study established age variation in the association between ICU stay and survival after HTx, with this association being strongest among adults, 40 to 49 years of age, undergoing HTx. Previous data suggesting decreased survival in infants may be related to the increased use of extracorporeal membrane oxygenation as a mechanical cardiac assist rather than ventricular assist devices.
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Affiliation(s)
- Trent Sims
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatric Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Dmitry Tumin
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Don Hayes
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.,Department of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pulmonary Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatric Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.,Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
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6
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Chen CK, Manlhiot C, Mital S, Schwartz SM, Van Arsdell GS, Caldarone C, McCrindle BW, Dipchand AI. Prelisting predictions of early postoperative survival in infant heart transplantation using classification and regression tree analysis. Pediatr Transplant 2018; 22. [PMID: 29271030 DOI: 10.1111/petr.13105] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/29/2017] [Indexed: 11/27/2022]
Abstract
Infants listed for heart transplantation experience high waitlist and early post-transplant mortality, and thus, optimal allocation of scarce donor organs is required. Unfortunately, the creation and validation of multivariable regression models to identify risk factors and generate individual-level predictions are challenging. We sought to explore the use of data mining methods to generate a prediction model. CART analysis was used to create a model which, at the time of listing, would predict which infants listed for heart transplantation would survive at least 3 months post-transplantation. A total of 48 infants were included; 13 died while waiting, and six died within 3 months of heart transplant. CART analysis identified RRT, blood urea nitrogen, and hematocrit as terminal nodes with alanine transaminase as an intermediate node predicting death. No patients listed on RRT (n = 10) survived and only three of 12 (25%) patients listed on ECLS survived >3 months post-transplant. CART analysis overall accuracy was 83%, with sensitivity of 95% and specificity 76%. This study shows that CART analysis can be used to generate accurate prediction models in small patient populations. Model validation will be necessary before incorporation into decision-making algorithms used to determine transplant candidacy.
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Affiliation(s)
- Ching Kit Chen
- Cardiology Service, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore City, Singapore
| | - Cedric Manlhiot
- Department of Pediatrics, Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Seema Mital
- Department of Pediatrics, Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Steven M Schwartz
- Department of Pediatrics, Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Glen S Van Arsdell
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Christopher Caldarone
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Brian W McCrindle
- Department of Pediatrics, Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Anne I Dipchand
- Department of Pediatrics, Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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7
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Ross HJ, Law Y, Book WM, Broberg CS, Burchill L, Cecchin F, Chen JM, Delgado D, Dimopoulos K, Everitt MD, Gatzoulis M, Harris L, Hsu DT, Kuvin JT, Martin CM, Murphy AM, Singh G, Spray TL, Stout KK. Transplantation and Mechanical Circulatory Support in Congenital Heart Disease. Circulation 2016; 133:802-20. [DOI: 10.1161/cir.0000000000000353] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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8
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Affiliation(s)
- Daphne T Hsu
- From the Division of Pediatric Cardiology, Department of Pediatrics, Albert Einstein College of Medicine and the Children's Hospital at Montefiore, Bronx, NY.
| | - Jacqueline M Lamour
- From the Division of Pediatric Cardiology, Department of Pediatrics, Albert Einstein College of Medicine and the Children's Hospital at Montefiore, Bronx, NY
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9
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Alexander PMA, Swager A, Lee KJ, Shipp A, Konstantinov IE, Wilkinson JL, d'Udekem Y, Brizard C, Weintraub RG. Paediatric heart transplantation in Australia comes of age: 21 years of experience in a national centre. Intern Med J 2014; 44:1223-31. [DOI: 10.1111/imj.12567] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 08/20/2014] [Indexed: 11/26/2022]
Affiliation(s)
- P. M. A. Alexander
- Boston Children's Hospital; Boston Massachusetts USA
- Royal Children's Hospital; Melbourne Victoria Australia
- Murdoch Children's Research Institute; Melbourne Victoria Australia
| | - A. Swager
- Royal Children's Hospital; Melbourne Victoria Australia
| | - K. J. Lee
- Murdoch Children's Research Institute; Melbourne Victoria Australia
- The University of Melbourne; Melbourne Victoria Australia
| | - A. Shipp
- Royal Children's Hospital; Melbourne Victoria Australia
| | - I. E. Konstantinov
- Royal Children's Hospital; Melbourne Victoria Australia
- Murdoch Children's Research Institute; Melbourne Victoria Australia
- The University of Melbourne; Melbourne Victoria Australia
| | - J. L. Wilkinson
- Royal Children's Hospital; Melbourne Victoria Australia
- The University of Melbourne; Melbourne Victoria Australia
| | - Y. d'Udekem
- Royal Children's Hospital; Melbourne Victoria Australia
- Murdoch Children's Research Institute; Melbourne Victoria Australia
- The University of Melbourne; Melbourne Victoria Australia
| | - C. Brizard
- Royal Children's Hospital; Melbourne Victoria Australia
- Murdoch Children's Research Institute; Melbourne Victoria Australia
- The University of Melbourne; Melbourne Victoria Australia
| | - R. G. Weintraub
- Royal Children's Hospital; Melbourne Victoria Australia
- Murdoch Children's Research Institute; Melbourne Victoria Australia
- The University of Melbourne; Melbourne Victoria Australia
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10
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Luk A, Ross HJ. "Please Sir, I want some more?"… Charles Dickens, Oliver Twist. J Heart Lung Transplant 2014; 33:231-2. [PMID: 24559942 DOI: 10.1016/j.healun.2013.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2013] [Accepted: 12/20/2013] [Indexed: 10/25/2022] Open
Affiliation(s)
- Adriana Luk
- Department of Medicine, Division of Cardiology, Toronto General Hospital, Toronto, Ontario, Canada
| | - Heather J Ross
- Department of Medicine, Division of Cardiology, Toronto General Hospital, Toronto, Ontario, Canada
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11
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Risk factors for mortality or delisting of patients from the pediatric heart transplant waiting list. J Thorac Cardiovasc Surg 2013; 147:462-8. [PMID: 24183905 DOI: 10.1016/j.jtcvs.2013.09.018] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Revised: 08/12/2013] [Accepted: 09/08/2013] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Current literature assessing factors associated with outcomes of patients waiting for pediatric heart transplants has focused on survival to transplant and mortality. Our aim was to determine risk factors associated with the outcomes of delisting, transplant, or death while waiting. METHODS In this single-center, retrospective study of patients listed for heart transplants, competing risk analysis was used to model survival from listing to 4 competing outcomes (transplant, death, delisting for clinical deterioration, delisting for clinical improvement or surgical intervention). RESULTS There were 308 listing episodes in 280 patients. In competing risk analysis, 11% remained listed at 6 months (transplant 62%, dead 13%, delisted worse 6%, delisted improved 8%). Extracorporeal membrane oxygenation and ventricular assist devices were associated both with higher probability of transplant (hazard ratio [HR], 2.8; P < .001) and delisting for clinical deterioration (HR, 2.7; P = .06). Younger age at listing and complex congenital heart disease were shared risk factors for mortality (HR, 1.07; P = .05; HR, 2.9; P = .003) and delisting because of clinical deterioration (HR, 1.17; P = .01; HR, 2.8; P = .02). Younger age at listing and fetal listing were associated with delisting for clinical improvement or surgical intervention (HR, 1.13; P = .01; HR, 2.9; P = .02). CONCLUSIONS Overall survival to transplant depends on risk factors including age at listing, cardiac diagnosis, and mechanical circulatory support. Knowledge of risk factors for death and delisting for clinical deterioration or improvement can assist patient selection and timing of transplant listing.
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12
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Everitt MD, Boyle GJ, Schechtman KB, Zheng J, Bullock EA, Kaza AK, Dipchand AI, Naftel DC, Kirklin JK, Canter CE. Early survival after heart transplant in young infants is lowest after failed single-ventricle palliation: A multi-institutional study. J Heart Lung Transplant 2012; 31:509-16. [DOI: 10.1016/j.healun.2011.12.013] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Revised: 11/10/2011] [Accepted: 12/14/2011] [Indexed: 11/26/2022] Open
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Almond CS, Gauvreau K, Canter CE, Rajagopal SK, Piercey GE, Singh TP. A risk-prediction model for in-hospital mortality after heart transplantation in US children. Am J Transplant 2012; 12:1240-8. [PMID: 22300640 DOI: 10.1111/j.1600-6143.2011.03932.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We sought to develop and validate a quantitative risk-prediction model for predicting the risk of posttransplant in-hospital mortality in pediatric heart transplantation (HT). Children <18 years of age who underwent primary HT in the United States during 1999-2008 (n = 2707) were identified using Organ Procurement and Transplant Network data. A risk-prediction model was developed using two-thirds of the cohort (random sample), internally validated in the remaining one-third, and independently validated in a cohort of 338 children transplanted during 2009-2010. The best predictive model had four categorical variables: hemodynamic support (ECMO, ventilator support, VAD support vs. medical therapy), cardiac diagnosis (repaired congenital heart disease [CHD], unrepaired CHD vs. cardiomyopathy), renal dysfunction (severe, mild-moderate vs. normal) and total bilirubin (≥ 2.0, 0.6 to <2.0 vs. <0.6 mg/dL). The C-statistic (0.78) and the Hosmer-Lemeshow goodness-of-fit (p = 0.89) in the model-development cohort were replicated in the internal validation and independent validation cohorts (C-statistic 0.75, 0.81 and the Hosmer-Lemeshow goodness-of-fit p = 0.49, 0.53, respectively) suggesting acceptable prediction for posttransplant in-hospital mortality. We conclude that this risk-prediction model using four factors at the time of transplant has good prediction characteristics for posttransplant in-hospital mortality in children and may be useful to guide decision-making around patient listing for transplant and timing of mechanical support.
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Affiliation(s)
- C S Almond
- Department of Cardiology, Children's Hospital, Boston, MA, USA.
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14
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Pauliks LB, Ündar A. Heart Transplantation for Congenital Heart Disease. World J Pediatr Congenit Heart Surg 2011; 2:603-8. [DOI: 10.1177/2150135111410078] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Congenital heart disease affects 0.8% of all live-born infants. Some of the malformed hearts can at best be palliated by conventional surgical or catheter interventions from the start. Others fail slowly from chronic overloading. Patients with congenital heart disease have been among the first transplant recipients since 1967. Primary therapy with infant heart transplant is a convincing concept from an immunological perspective but large-scale implementation is limited by donor organ shortages. Another growing area is rescue therapy for older patients with end-stage heart failure after palliative procedures, particularly those with single-ventricle hearts, systemic right ventricles, and associated arrhythmias.
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Affiliation(s)
- Linda B. Pauliks
- Pediatric Cardiology, Department of Pediatrics, Penn State Hershey Children’s Hospital, Hershey, PA, USA
- Department of Pediatrics, Penn State Hershey Pediatric Cardiovascular Research Center, Hershey, PA, USA
| | - Akif Ündar
- Pediatric Cardiology, Department of Pediatrics, Penn State Hershey Children’s Hospital, Hershey, PA, USA
- Department of Pediatrics, Penn State Hershey Pediatric Cardiovascular Research Center, Hershey, PA, USA
- Department of Surgery, Penn State Milton S. Hershey Medical Center, Penn State Hershey College of Medicine, Penn State Hershey Children’s Hospital, Hershey, PA, USA
- Department of Bioengineering, Penn State Milton S. Hershey Medical Center, Penn State Hershey College of Medicine, Penn State Hershey Children’s Hospital, Hershey, PA, USA
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15
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Almond CS, Singh TP, Gauvreau K, Piercey GE, Fynn-Thompson F, Rycus PT, Bartlett RH, Thiagarajan RR. Extracorporeal Membrane Oxygenation for Bridge to Heart Transplantation Among Children in the United States. Circulation 2011; 123:2975-84. [DOI: 10.1161/circulationaha.110.991505] [Citation(s) in RCA: 148] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Extracorporeal membrane oxygenation (ECMO) has served for >2 decades as the standard of care for US children requiring mechanical support as a bridge to heart transplantation. Objective data on the safety and efficacy of ECMO for this indication are limited. We describe the outcomes of ECMO as a bridge to heart transplantation to serve as performance benchmarks for emerging miniaturized assist devices intended to replace ECMO.
Methods and Results—
Data from the Extracorporeal Life Support Organization Registry and the Organ Procurement Transplant Network database were merged to identify children supported with ECMO and listed for heart transplantation from 1994 to 2009. Independent predictors of wait-list and posttransplantation in-hospital mortality were identified. Objective performance goals for ECMO were developed. Of 773 children, the median age was 6 months (interquartile range, 1 to 44 months); 28% had cardiomyopathy; and in 38%, a bridge to transplantation was intended at ECMO initiation. Overall, 45% of subjects reached transplantation, although one third of those transplanted died before discharge; overall survival to hospital discharge was 47%. Wait-list mortality was independently associated with congenital heart disease, cardiopulmonary resuscitation before ECMO, and renal dysfunction. Posttransplantation mortality was associated with congenital heart disease, renal dysfunction, ECMO duration of >14 days, and initial ECMO indication as a bridge to recovery. In the objective performance goal cohort (n=485), patients with cardiomyopathy had the highest survival to hospital discharge (63%), followed by patients with myocarditis (59%), 2-ventricle congenital heart disease (44%) and 1-ventricle congenital heart disease (33%).
Conclusion—
Although ECMO is effective for short-term circulatory support, it is not reliable for the long-term circulatory support necessary for children awaiting heart transplantation. Fewer than half of patients bridged with ECMO survive to hospital discharge. More effective modalities for chronic circulatory support in children are urgently needed.
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Affiliation(s)
- Christopher S. Almond
- From the Departments of Cardiology (C.S.A., T.P.S., K.G., G.E.P., T.P.S.) and Cardiac Surgery (F.F.T.), Children's Hospital Boston, Boston, MA; Departments of Pediatrics (C.S.A., T.P.S., K.G., R.R.T.) and Surgery (F.F.T.), Harvard Medical School, Boston, MA; Extracorporeal Life Support Organization, Ann Arbor, MI (P.T.R., R.H.B.); and Department of Biostatistics, Harvard School of Public Health, Boston, MA (K.G.)
| | - Tajinder P. Singh
- From the Departments of Cardiology (C.S.A., T.P.S., K.G., G.E.P., T.P.S.) and Cardiac Surgery (F.F.T.), Children's Hospital Boston, Boston, MA; Departments of Pediatrics (C.S.A., T.P.S., K.G., R.R.T.) and Surgery (F.F.T.), Harvard Medical School, Boston, MA; Extracorporeal Life Support Organization, Ann Arbor, MI (P.T.R., R.H.B.); and Department of Biostatistics, Harvard School of Public Health, Boston, MA (K.G.)
| | - Kimberlee Gauvreau
- From the Departments of Cardiology (C.S.A., T.P.S., K.G., G.E.P., T.P.S.) and Cardiac Surgery (F.F.T.), Children's Hospital Boston, Boston, MA; Departments of Pediatrics (C.S.A., T.P.S., K.G., R.R.T.) and Surgery (F.F.T.), Harvard Medical School, Boston, MA; Extracorporeal Life Support Organization, Ann Arbor, MI (P.T.R., R.H.B.); and Department of Biostatistics, Harvard School of Public Health, Boston, MA (K.G.)
| | - Gary E. Piercey
- From the Departments of Cardiology (C.S.A., T.P.S., K.G., G.E.P., T.P.S.) and Cardiac Surgery (F.F.T.), Children's Hospital Boston, Boston, MA; Departments of Pediatrics (C.S.A., T.P.S., K.G., R.R.T.) and Surgery (F.F.T.), Harvard Medical School, Boston, MA; Extracorporeal Life Support Organization, Ann Arbor, MI (P.T.R., R.H.B.); and Department of Biostatistics, Harvard School of Public Health, Boston, MA (K.G.)
| | - Francis Fynn-Thompson
- From the Departments of Cardiology (C.S.A., T.P.S., K.G., G.E.P., T.P.S.) and Cardiac Surgery (F.F.T.), Children's Hospital Boston, Boston, MA; Departments of Pediatrics (C.S.A., T.P.S., K.G., R.R.T.) and Surgery (F.F.T.), Harvard Medical School, Boston, MA; Extracorporeal Life Support Organization, Ann Arbor, MI (P.T.R., R.H.B.); and Department of Biostatistics, Harvard School of Public Health, Boston, MA (K.G.)
| | - Peter T. Rycus
- From the Departments of Cardiology (C.S.A., T.P.S., K.G., G.E.P., T.P.S.) and Cardiac Surgery (F.F.T.), Children's Hospital Boston, Boston, MA; Departments of Pediatrics (C.S.A., T.P.S., K.G., R.R.T.) and Surgery (F.F.T.), Harvard Medical School, Boston, MA; Extracorporeal Life Support Organization, Ann Arbor, MI (P.T.R., R.H.B.); and Department of Biostatistics, Harvard School of Public Health, Boston, MA (K.G.)
| | - Robert H. Bartlett
- From the Departments of Cardiology (C.S.A., T.P.S., K.G., G.E.P., T.P.S.) and Cardiac Surgery (F.F.T.), Children's Hospital Boston, Boston, MA; Departments of Pediatrics (C.S.A., T.P.S., K.G., R.R.T.) and Surgery (F.F.T.), Harvard Medical School, Boston, MA; Extracorporeal Life Support Organization, Ann Arbor, MI (P.T.R., R.H.B.); and Department of Biostatistics, Harvard School of Public Health, Boston, MA (K.G.)
| | - Ravi R. Thiagarajan
- From the Departments of Cardiology (C.S.A., T.P.S., K.G., G.E.P., T.P.S.) and Cardiac Surgery (F.F.T.), Children's Hospital Boston, Boston, MA; Departments of Pediatrics (C.S.A., T.P.S., K.G., R.R.T.) and Surgery (F.F.T.), Harvard Medical School, Boston, MA; Extracorporeal Life Support Organization, Ann Arbor, MI (P.T.R., R.H.B.); and Department of Biostatistics, Harvard School of Public Health, Boston, MA (K.G.)
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16
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Almond CS, Gauvreau K, Thiagarajan RR, Piercey GE, Blume ED, Smoot LB, Fynn-Thompson F, Singh TP. Impact of ABO-incompatible listing on wait-list outcomes among infants listed for heart transplantation in the United States: a propensity analysis. Circulation 2010; 121:1926-33. [PMID: 20404257 DOI: 10.1161/circulationaha.109.885756] [Citation(s) in RCA: 50] [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 The purported advantage of ABO-incompatible (ABO-I) listing is to reduce wait times and wait-list mortality among infants awaiting heart transplantation. We sought to describe recent trends in ABO-I listing for US infants and to determine the impact of ABO-I listing on wait times and wait-list mortality. METHODS AND RESULTS In this multicenter retrospective cohort study using Organ Procurement and Transplant Network data, infants<12 months of age listed for heart transplantation between 1999 and 2008 (n=1331) were analyzed. Infants listed for an ABO-I transplant were compared with a propensity score-matched cohort listed for an ABO-compatible transplant through the use of a Cox shared-frailty model. The primary end point was time to heart transplantation. The percentage of eligible infants listed for an ABO-I heart increased from 0% before 2002 to 53% in 2007 (P<0.001 for trend). Compared with infants listed exclusively for an ABO-compatible heart, infants with a primary ABO-I listing strategy (n=235) were more likely to be listed 1A, to have congenital heart disease and renal failure, and to require extracorporeal membrane oxygenation. For the propensity score-matched groups (n=197 matched pairs), there was no difference in wait-list mortality; however, infants with blood type O assigned an ABO-I listing strategy were more likely to undergo heart transplantation by 30 days (31% versus 16%; P=0.007) with a less pronounced effect for infants with other blood types. CONCLUSIONS The proportion of US infants listed for an ABO-I heart transplantation has risen dramatically in recent years but still appears to be preferentially used for sicker infant candidates. The ABO-I listing strategy is associated with a higher likelihood of transplantation within 30 days for infants with blood group O and may benefit a broader range of transplantation candidates.
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Affiliation(s)
- Christopher S Almond
- Department of Cardiology, Children's Hospital Boston, and Department of Pediatrics, Harvard Medical School, 300 Longwood Ave, Boston, MA 02115, USA.
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Abstract
In the last 40 years, orthotopic heart transplantation has been established as a realistic treatment strategy for infants and children with severe forms of congenital heart disease and cardiomyopathy. The evaluation, management, and outcomes of these patients have continued to improve. These achievements have advanced pediatric cardiac transplantation and allowed more attention to be focused on improving quality of life after transplantation and reducing the long-term complications.
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Affiliation(s)
- Jennifer Conway
- Labatt Family Heart Centre, Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
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18
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Gazit AZ, Huddleston CB, Checchia PA, Fehr J, Pezzella AT. Care of the pediatric cardiac surgery patient--part 2. Curr Probl Surg 2010; 47:261-376. [PMID: 20207257 DOI: 10.1067/j.cpsurg.2009.12.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Avihu Z Gazit
- Pediatric Critical Care Medicine and Cardiology, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri, USA
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19
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Mah D, Singh TP, Thiagarajan RR, Gauvreau K, Piercey GE, Blume ED, Fynn-Thompson F, Almond CSD. Incidence and risk factors for mortality in infants awaiting heart transplantation in the USA. J Heart Lung Transplant 2009; 28:1292-8. [PMID: 19782580 DOI: 10.1016/j.healun.2009.06.013] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2009] [Revised: 06/08/2009] [Accepted: 06/10/2009] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Infants awaiting heart transplantation (HT) face the highest wait-list mortality among all children and adults listed for HT in the USA. We sought to determine the risk of death for infants <12 months old while awaiting HT in the current era, and to identify the principle risk factors associated with wait-list mortality. METHODS We analyzed outcomes for all infants listed for HT in the USA from January 1999 to July 2006, using data reported to the U.S. Scientific Registry of Transplant Recipients. RESULTS Of the 1,133 listed infants, 61% were <3 months of age, 80% were listed as Status 1A, 64% had a congenital heart disease (CHD) and 31% had cardiomyopathy. Of 724 infants with CHD, 25% were on prostaglandin (PG) and 27% had a history of prior surgery. By 6 months after listing, 23% died on the wait-list and 54% were transplanted. Multivariate factors associated with wait-list mortality were weight <3 kg (hazard ratio [HR] 1.4, 95% confidence interval [CI] 1.0 to 1.9), extracorporeal membrane oxygenation (ECMO) support (HR 5.6, CI 4.0 to 7.9), ventilator support (HR 2.1, 95% CI 1.6 to 2.8), CHD with PG support (HR 2.8, 95% CI 1.8 to 4.3), CHD without prior surgery (HR 2.8, 95% CI 1.9 to 3.9) and non-white race/ethnicity (HR 1.8, 95% CI 1.4 to 2.3). CONCLUSIONS One in four infants listed for HT in the USA die before a donor heart can be identified. Wait-list mortality is associated with weight <3 kg, level of invasive support and CHD, but not listing status, which captures medical urgency poorly. Measures to expand infant organ donation, especially among neonates, are urgently needed.
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Affiliation(s)
- Douglas Mah
- Department of Cardiology, Children's Hospital, Boston, Massachusetts 02115, USA
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20
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Almond CSD, Thiagarajan RR, Piercey GE, Gauvreau K, Blume ED, Bastardi HJ, Fynn-Thompson F, Singh TP. Waiting list mortality among children listed for heart transplantation in the United States. Circulation 2009; 119:717-727. [PMID: 19171850 DOI: 10.1161/circulationaha.108.815712] [Citation(s) in RCA: 277] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Children listed for heart transplantation face the highest waiting list mortality in solid-organ transplantation medicine. We examined waiting list mortality since the pediatric heart allocation system was revised in 1999 to determine whether the revised allocation system is prioritizing patients optimally and to identify specific high-risk populations that may benefit from emerging pediatric cardiac assist devices. METHODS AND RESULTS We conducted a multicenter cohort study using the US Scientific Registry of Transplant Recipients. All children <18 years of age who were listed for a heart transplant between 1999 and 2006 were included. Among 3098 children, the median age was 2 years (interquartile range 0.3 to 12 years), and median weight was 12.3 kg (interquartile range 5 to 38 kg); 1294 (42%) were nonwhite; and 1874 (60%) were listed as status 1A (of whom 30% were ventilated and 18% were on extracorporeal membrane oxygenation). Overall, 533 (17%) died, 1943 (63%) received transplants, and 252 (8%) recovered; 370 (12%) remained listed. Multivariate predictors of waiting list mortality include extracorporeal membrane oxygenation support (hazard ratio [HR] 3.1, 95% confidence interval [CI] 2.4 to 3.9), ventilator support (HR 1.9, 95% CI 1.6 to 2.4), listing status 1A (HR 2.2, 95% CI 1.7 to 2.7), congenital heart disease (HR 2.2, 95% CI 1.8 to 2.6), dialysis support (HR 1.9, 95% CI 1.2 to 3.0), and nonwhite race/ethnicity (HR 1.7, 95% CI 1.4 to 2.0). CONCLUSIONS US waiting list mortality for pediatric heart transplantation remains unacceptably high in the current era. Specific high-risk subgroups can be identified that may benefit from emerging pediatric cardiac assist technologies. The current pediatric heart-allocation system captures medical urgency poorly. Further research is needed to define the optimal organ-allocation system for pediatric heart transplantation.
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Affiliation(s)
- Christopher S D Almond
- Department of Cardiology (C.S.D.A., R.R.T., G.E.P., K.G., E.D.B., H.J.B., T.P.S.), Cardiac Surgery (F.F.T.), and the Pediatric Transplant Center (C.S.D.A., E.D.B., H.J.B., F.F.T., T.P.S.), Children's Hospital Boston; the Department of Pediatrics, Harvard Medical School; and the Department of Biostatistics (K.G.), Harvard School of Public Health; all in Boston, Mass
| | - Ravi R Thiagarajan
- Department of Cardiology (C.S.D.A., R.R.T., G.E.P., K.G., E.D.B., H.J.B., T.P.S.), Cardiac Surgery (F.F.T.), and the Pediatric Transplant Center (C.S.D.A., E.D.B., H.J.B., F.F.T., T.P.S.), Children's Hospital Boston; the Department of Pediatrics, Harvard Medical School; and the Department of Biostatistics (K.G.), Harvard School of Public Health; all in Boston, Mass
| | - Gary E Piercey
- Department of Cardiology (C.S.D.A., R.R.T., G.E.P., K.G., E.D.B., H.J.B., T.P.S.), Cardiac Surgery (F.F.T.), and the Pediatric Transplant Center (C.S.D.A., E.D.B., H.J.B., F.F.T., T.P.S.), Children's Hospital Boston; the Department of Pediatrics, Harvard Medical School; and the Department of Biostatistics (K.G.), Harvard School of Public Health; all in Boston, Mass
| | - Kimberlee Gauvreau
- Department of Cardiology (C.S.D.A., R.R.T., G.E.P., K.G., E.D.B., H.J.B., T.P.S.), Cardiac Surgery (F.F.T.), and the Pediatric Transplant Center (C.S.D.A., E.D.B., H.J.B., F.F.T., T.P.S.), Children's Hospital Boston; the Department of Pediatrics, Harvard Medical School; and the Department of Biostatistics (K.G.), Harvard School of Public Health; all in Boston, Mass
| | - Elizabeth D Blume
- Department of Cardiology (C.S.D.A., R.R.T., G.E.P., K.G., E.D.B., H.J.B., T.P.S.), Cardiac Surgery (F.F.T.), and the Pediatric Transplant Center (C.S.D.A., E.D.B., H.J.B., F.F.T., T.P.S.), Children's Hospital Boston; the Department of Pediatrics, Harvard Medical School; and the Department of Biostatistics (K.G.), Harvard School of Public Health; all in Boston, Mass
| | - Heather J Bastardi
- Department of Cardiology (C.S.D.A., R.R.T., G.E.P., K.G., E.D.B., H.J.B., T.P.S.), Cardiac Surgery (F.F.T.), and the Pediatric Transplant Center (C.S.D.A., E.D.B., H.J.B., F.F.T., T.P.S.), Children's Hospital Boston; the Department of Pediatrics, Harvard Medical School; and the Department of Biostatistics (K.G.), Harvard School of Public Health; all in Boston, Mass
| | - Francis Fynn-Thompson
- Department of Cardiology (C.S.D.A., R.R.T., G.E.P., K.G., E.D.B., H.J.B., T.P.S.), Cardiac Surgery (F.F.T.), and the Pediatric Transplant Center (C.S.D.A., E.D.B., H.J.B., F.F.T., T.P.S.), Children's Hospital Boston; the Department of Pediatrics, Harvard Medical School; and the Department of Biostatistics (K.G.), Harvard School of Public Health; all in Boston, Mass
| | - T P Singh
- Department of Cardiology (C.S.D.A., R.R.T., G.E.P., K.G., E.D.B., H.J.B., T.P.S.), Cardiac Surgery (F.F.T.), and the Pediatric Transplant Center (C.S.D.A., E.D.B., H.J.B., F.F.T., T.P.S.), Children's Hospital Boston; the Department of Pediatrics, Harvard Medical School; and the Department of Biostatistics (K.G.), Harvard School of Public Health; all in Boston, Mass
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21
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Hartyánszky I, Ablonczy L, Bodor E, Hartyánszky I, Bodor G, Mihályi S, Sápi E, Héthársi B, Szatmári A. [Role of heart transplantation in pediatric heart surgery. The first successful pediatric heart transplantation in Hungary]. Orv Hetil 2008; 149:1035-7. [PMID: 18508738 DOI: 10.1556/oh.2008.28348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
7-year-old boy, who underwent aortic valve replacement two years previously, suffered from idiopathic dilated cardiomyopathy. Because of poor condition (NYHA-IV), heart transplantation was performed on 18th October 2007. It was the first pediatric heart transplantation in Hungary. It was an uneventful early postoperative period, 6 months after the operation he is doing well, no biopsy-proven and tissue Doppler echocardiography (TDI-derived velocities measurement) rejection was detected. The immunosuppression was based on triple-drug therapy (tacrolimus+mycophenolate mofetil+corticosteroid) with use of induction therapy with interleukin-2 receptor blocker (basiliximab).
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22
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Numerical design and experimental hydraulic testing of an axial flow ventricular assist device for infants and children. ASAIO J 2008; 53:754-61. [PMID: 18043161 DOI: 10.1097/mat.0b013e31815581ea] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Mechanical circulatory support options for infants and children are very limited in the United States. Existing circulatory support systems have proven successful for short-term pediatric assist, but are not completely successful as a bridge-to-transplant or bridge-to-recovery. To address this substantial need for alternative pediatric mechanical assist, we are developing a novel, magnetically levitated, axial flow pediatric ventricular assist device (PVAD) intended for longer-term ventricular support. Three major numerical design and optimization phases have been completed. A prototype was built based on the latest numerical design (PVAD3) and hydraulically tested in a flow loop. The plastic PVAD prototype delivered 0.5-4 lpm, generating pressure rises of 50-115 mm Hg for operating speeds of 6,000-9,000 rpm. The experimental testing data and the numerical predictions correlated well. The error between these sets of data was found to be generally 7.8% with a maximum deviation of 24% at higher flow rates. The axial fluid forces for the numerical simulations ranged from 0.5 to 1 N and deviated from the experimental results by generally 8.5% with a maximum deviation of 12% at higher flow rates. These hydraulic results demonstrate the excellent performance of the PVAD3 and illustrate the achievement of the design objectives.
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23
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Tjang YS, Stenlund H, Tenderich G, Hornik L, Körfer R. Pediatric Heart Transplantation: Current Clinical Review. J Card Surg 2008; 23:87-91. [DOI: 10.1111/j.1540-8191.2007.00494.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Chu MWA, Sharma K, Tchervenkov CI, Jutras LF, Lavoie J, Shemie SD, Laliberte E, Calaritis C, Cecere R. Berlin Heart Ventricular Assist Device in a Child With Hypoplastic Left Heart Syndrome. Ann Thorac Surg 2007; 83:1179-81. [PMID: 17307489 DOI: 10.1016/j.athoracsur.2006.08.020] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2006] [Revised: 08/05/2006] [Accepted: 08/09/2006] [Indexed: 11/24/2022]
Abstract
We report the implantation of a Berlin Heart ventricular assist device (VAD) in a 4-year-old boy with hypoplastic left heart syndrome previously palliated with Norwood and Glenn operations, who presented with progressive ventricular failure and hypoxemia. Insertion of a 30-mL pneumatic pediatric pump with cannulation of the systemic right ventricle and aorta had a salutary effect on cardiac output, improving oxygen saturations. While awaiting heart transplantation, multiple thromboembolic complications developed and he died, despite therapeutic heparinization and aspirin therapy. Important lessons learned about VAD support in Glenn physiology, anticoagulation, and complications of the Berlin Heart are discussed.
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Affiliation(s)
- Michael W A Chu
- Division of Pediatric Cardiovascular Surgery, Montreal Children's Hospital, Montréal, Québec, Canada
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25
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Canter CE, Shaddy RE, Bernstein D, Hsu DT, Chrisant MRK, Kirklin JK, Kanter KR, Higgins RSD, Blume ED, Rosenthal DN, Boucek MM, Uzark KC, Friedman AH, Friedman AH, Young JK. Indications for Heart Transplantation in Pediatric Heart Disease. Circulation 2007; 115:658-76. [PMID: 17261651 DOI: 10.1161/circulationaha.106.180449] [Citation(s) in RCA: 175] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Since the initial utilization of heart transplantation as therapy for end-stage pediatric heart disease, improvements have occurred in outcomes with heart transplantation and surgical therapies for congenital heart disease along with the application of medical therapies to pediatric heart failure that have improved outcomes in adults. These events justify a reevaluation of the indications for heart transplantation in congenital heart disease and other causes of pediatric heart failure.
Methods and Results—
A working group was commissioned to review accumulated experience with pediatric heart transplantation and its use in patients with unrepaired and/or previously repaired or palliated congenital heart disease (children and adults), in patients with pediatric cardiomyopathies, and in pediatric patients with prior heart transplantation. Evidence-based guidelines for the indications for heart transplantation or retransplantation for these conditions were developed.
Conclusions—
This evaluation has led to the development and refinement of indications for heart transplantation for patients with congenital heart disease and pediatric cardiomyopathies in addition to indications for pediatric heart retransplantation.
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Kirklin JK, Naftel DC, Caldwell RL, Pearce FB, Bartlett H, Rusconi P, White-Williams C, Robinson BV. Should status II patients be removed from the pediatric heart transplant waiting list? A multi-institutional study. J Heart Lung Transplant 2006; 25:271-5. [PMID: 16507418 DOI: 10.1016/j.healun.2005.10.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2005] [Revised: 09/12/2005] [Accepted: 10/05/2005] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The survival benefit of cardiac transplantation (CTx) among Status 2 (stable outpatient) adult recipients has been questioned, but few studies have addressed this issue in pediatric patients. This study examined the following hypothesis: "Status 2 pediatric recipients have a survival benefit with CTx." METHODS Between 1993 and 2003, 2,375 patients were listed for CTx at 24 institutions; 614 (26%) of these patients were Status 2. By multivariate competing outcomes hazard function analysis, death after listing and post-transplant survival were analyzed. RESULTS A single-phase hazard function described the risk of death after listing, with 20% actual mortality within 2 months after Status 1 listing. The "natural history" of Status 2-listed patients was estimated by the risk of death, whereas waiting and risk of deterioration to Status 1 at CTx (weighted by the probability of death at 3 months after Status 1 listing). At 4 months after CTx, survival with CTx exceeded the predicted "natural Hx" survival in all diagnostic categories out to 4 years of follow-up. CONCLUSIONS Pediatric patients currently listed as Status 2 have a survival benefit with transplant out to at least 4 years. A pediatric allocation system restricted to Status 1 patients could only be justified if the vast majority of such patients could be transplanted within 1 to 2 months.
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Affiliation(s)
- J K Kirklin
- University of Alabama at Birmingham, Birmingham, Alabama 35294, USA.
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27
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Odim J, Laks H, Banerji A, Mukherjee K, Vincent C, Murphy C, Burch C, Gjertson D. Does duration of donor brain injury affect outcome after orthotopic pediatric heart transplantation? J Thorac Cardiovasc Surg 2005; 130:187-93. [PMID: 15999061 DOI: 10.1016/j.jtcvs.2005.02.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We tested the hypothesis that duration of donor brain injury and death would have an adverse effect on recipient rejection and mortality in pediatric heart transplantation. METHODS Ninety-three cardiac transplants were performed at our center from July 1, 1997, through June 30, 2003. The primary study end points were the number of rejection episodes and the time to first rejection. Secondary outcomes were early and late mortality. RESULTS Among 88 recipients of 93 cardiac allografts, 5 (6%) and 1 (1%) received second and third allografts, respectively. Overall patient mortality (3 early and 2 late) was 6% (5/88), and overall graft loss was 6% (6/93). Median time from donor brain injury to declaration of brain death (brain injury interval), time from brain death to donor cardiectomy (brain death interval), and graft ischemia time were 38, 24, and 3.3 hours, respectively. Cox regression analysis (adjusting for United Network for Organ Sharing status, ventilator dependence, extracorporeal membrane oxygenation and ventricular-assist device status, diagnosis of congenital heart disease, sex and cytomegalovirus mismatches, and type of immunosuppression) demonstrated that recipients of donor hearts with relatively long periods from brain injury to death declaration or from death to organ removal had significantly improved rejection-free survival (hazard ratios 0.3, P = .01, and 0.5, P = .05, for brain injury and brain death times, respectively). Prolonged donor heart ischemia did not impact rejection rate. Increasing brain injury interval, brain death interval, and graft ischemia time had no significant effect on mortality. CONCLUSION Longer brain injury and death intervals correlated with improved freedom from rejection but had no effect on mortality.
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Affiliation(s)
- Jonah Odim
- Division of Cardiothoracic Surgery, David Geffen School of Medicine at UCLA, University of California-Los Angeles, 10833 Le Conte Avenue, Los Angeles, CA 90095-1741, USA.
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Azeka E, Auler JOC, Marcial MB, Fumagalli F, Ramires JAF. Heart transplantation in children: clinical outcome during the early postoperative period. Pediatr Transplant 2005; 9:491-7. [PMID: 16048602 DOI: 10.1111/j.1399-3046.2005.00333.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
As improved understanding of transplant-related death should improve survival, we report a single center's experience with pediatric heart transplantation including potential risk factors and causes of death during the early postoperative period. This prospective longitudinal study involved 51 pediatric patients ranging in age from 12 days to 15.1 yr (median: 3 yr). The following pretransplant risk factors were evaluated: diagnosis, age at transplantation, recipient sex, weight and blood type, blood type match, donor/recipient sex match, weight ratio, ischemic time, recipient's status, requirement for mechanical ventilation or circulatory support, dialysis, or inotropic support at transplantation. We also determined the actuarial survival, clinical outcomes, and causes of death in this population. Survival was 86% during the early postoperative period (</=30 days), 79.3% at 1 yr, and 76.8% at 3 yr. Seven patients died during the early postoperative period (primary graft failure, rejection, and infection). However, there was no difference in the frequency of any of the risk factors analyzed between these patients and those who did not experience early death. There was a correlation between the duration of intubation after transplantation and pretransplant risk factors (diagnosis, recipient status, requirement for dialysis, inotropic and mechanical ventilation support). Our findings indicate that promising short-term results can be obtained with pediatric transplantation. Although we identified no specific risk factors in this study for death, improved rejection surveillance and treatment strategies remain important goals in pediatric heart transplantation. Retransplantation had high mortality during the perioperative period.
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Affiliation(s)
- Estela Azeka
- Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil.
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Throckmorton AL, Untaroiu A, Allaire PE, Wood HG, Matherne GP, Lim DS, Peeler BB, Olsen DB. Computational Analysis of an Axial Flow Pediatric Ventricular Assist Device. Artif Organs 2004. [DOI: 10.1111/j.1525-1594.2004.00009_1.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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