Pediatric cardiac transplantation: management issues

Single center experience with ABO-incompatible and ABO-compatible pediatric heart transplantation

Introduction

The aim of this study was to analyze the results after pediatric heart transplantation (pHTx) at our single center differentiating between ABO-incompatible (ABOi) and -compatible (ABOc) procedures.

Methods and patients

We retrospectively analyzed outcomes of ABO-incompatible HTx procedures performed at our center and compared the data to ABO-compatible HTx of the same era. Eighteen children (<17 months) underwent pediatric HTx and seven of them underwent ABO-incompatible HTx between 2003 and 2015.

Results

Mechanical circulatory support as bridge to transplant was necessary in 3/7 patients before ABO-incompatible HTx and in 3/11 patients before ABO-compatible HTx. Mean waiting time on the list was 36 ± 30 days for ABO-incompatible HTx and 86 ± 65 days for ABO-compatible HTx. The 5-years re-transplant free survival was 86% following ABO-incompatible and 91% after ABO-compatible. In the cohort undergoing ABO-incompatible HTx, 2 patients showed an acute cellular rejection, while early graft failure was not observed. In the cohort undergoing ABOcompatible HTx, acute cellular rejection was observed in 9/11 patients, with early graft failure occurring in nine and CVP in two. A total of ten children were listed for ABO-incompatible HTx after 2015; however, all ten underwent an ABO-compatible transplantation.

Discussion

This study adds much needed information to the literature on ABOi-HTx by showing with a retrospective single center analysis that it is safe and leads to shorter waiting times. We conclude that strategies for ABOi-HTx should be elaborated further, potentially allowing more timely transplantation and thereby preventing waiting list complications such as the need for mechanical circulatory support and even death.

An educational design and development project for pediatric heart transplant recipients and their families

PURPOSE

The purpose of this project is to systematically derive and develop educational content for children who have undergone heart transplants and their families to improve the families' and caregivers' ability to manage child health in South Korea.

DESIGN AND METHODS

This project developed educational content through the first three steps: "Analysis," "Design," and "Development" of the five steps outlined in the ADDIE (Analysis, Design, Development, Implementation, and Evaluation) model. The educational contents were derived from an analysis of six literature reviews and six studies, seven websites, and interviews with six caregivers of children who have undergone a heart transplant. Based on these analyses, educational items were designed. When a draft of the education contents was developed, the content validity was validated by ten experts.

RESULTS

Educational items were designed in nine major categories and 40 sub-categories. All contents were validated with a content validity index of at least 0.8 or higher and included in the education content for pediatric heart transplant families, with recommendations for further modification based on expert advice.

PRACTICE IMPLICATIONS

This project is meaningful in that it has developed health management education contents suitable for the situation in South Korea through analyzing previous studies and educational contents of domestic and international medical centers as well as an in-depth interview with caregivers.

Nutrition Implications of Heart Failure and Heart Transplantation in Children With Dilated Cardiomyopathy

This article describes nutrition implications of pediatric dilated cardiomyopathy leading to heart transplantation with a focus on nutritional management of patients during the waiting time for a donor organ and the inpatient postoperative period. Optimization of nutritional status is essential during these periods as weight loss and malnutrition contribute to muscle atrophy, decreased functional capacity, reduced immune function, and prolonged hospital stay. Nutrition implications of heart failure vary with patient’s age and degree of symptoms. Infants may have increased caloric needs and poor feeding often due to tachypnea. Older children, 1-18 years, may have decreased appetite, abdominal pain, and vomiting. Ventricular assist devices or extracorporeal membrane oxygenation, necessary to sustain life in some cases, have additional nutrition implications related to wound healing from insertion of the device and device-related complications that can include pancreatitis and the need for total parenteral nutrition. Once symptomatic heart failure is relieved and heart transplant occurs, caloric needs often decrease while interest in eating can increase profoundly, changing the overall nutrition diagnosis and the need for nutrition support. A case series involving an infant, a young child, and an adolescent is presented to illustrate nutritional challenges and interventions for pediatric patients awaiting heart transplant and the inpatient postoperative period.

Pediatric cardiac transplants: a clinical update

In the last 10 years more than 2,600 pediatric patients have received heart transplants. The survival rate at 10 years is 65% (Blume, 2003). There have been profound improvements in the survival and quality of life associated with pediatric heart transplants. Due to the increase in survival and quality of life, it is becoming more common for nurses to care for these unique patients. Nurses need to be aware of the complex management of pediatric heart transplant patients to aid in their care of these patients. This paper will discuss the transplant process, medications, common complications, and psychosocial impact associated with pediatric heart transplants to better prepare nurses involved in the care of pediatric cardiac transplant patients.

Epicardial and microvascular graft vessel disease in children

AIM

Graft vessel disease (GVD) is one of the main limiting factors to long-term survival after adult heart transplantation (HTx). The incidence of epicardial and microvascular GVD in paediatric patients was studied.

METHODS

A total of 137 coronary angiographies from 130 paediatric HTx and heart and lung transplant (HLTx) patients (70 male, 60 female, aged 0-18 y) were evaluated according to the Stanford classification and its supplements (minor vessel alterations). In H&E stainings from right ventricular endomyocardial biopsies (EMB = 397), light microscopic diagnosis of acute cellular rejection (ISHLT classification) and vascular reaction (morphology of endothelial cells and vessel walls) was performed.

RESULTS

Moderate rejection was present in 32.8% and severe rejection in 13.3% of EMB. Microvascular EC swelling was found in 33.5% and vessel wall thickening in 53.8% of EMB. The results of the coronary angiographic investigations were: Stanford lesions = 61.2%, peripheral obliterations = 52.5%, diameter fluctuations = 86.3%, pathologic tapering = 64.0%, calcifications = 10.8%. Long-term survivors (> or =5 y) showed macrovascular alterations in 78% of cases and microvascular alterations in 67% of cases.

CONCLUSION

The development of micro- and macrovascular GVD is one of the predominant complications in long-term survivors after paediatric HTx and HLTx.