Cardiac retransplantation in children

Heart retransplantation for pediatric primary allograft failure

PURPOSE

Heart transplantation is indicated for children with end-stage heart failure or complex inoperable congenital defects. When the transplanted heart fails, retransplantation is suggested and herein we have presented the prognosis of these pediatric cases.

MATERIALS AND METHODS

From March 1987 to March 2011, we performed 404 heart transplantations including 45 pediatric patients, 6 (13.3%) of whom experienced graft failure requiring retransplantation. Only four of the six patients (66.7%) had a chance for retransplantation.

RESULTS

Six of 45 pediatric heart transplant patients (13.3%) experienced graft failure requiring retransplantation. Four of them (66.7%) underwent retransplantation. Only one of the four died due to severe postoperative sepsis with acute respiratory distress. The other three patients recovered well and remain alive with no neurological sequelae; all are in New York Heart Association functional classification I at present.

CONCLUSION

Pediatric post-heart graft failure require expectations retransplantation, which shows a good prognosis.

Organizational structure and processes in pediatric heart transplantation: a survey of practices

Despite emerging literature on pediatric heart transplantation, there continues to be variation in current practices. The degree of variability among heart transplant programs has not been previously characterized. The purpose of this study was to evaluate organizational structure and practices of pediatric heart transplant programs. The UNOS database was queried to identify institutions according to volume. Coordinators from 50 institutions were invited to participate with a 70% response rate. Centers were grouped by volume into four categories. Some institutional practices were dominated by clear volume trends. Ninety-five percent of larger centers routinely transplant patients with known antibody sensitization and report a broader range and acuity of recipients. Ninety-four percent report problems with non-adherence. Sixty-nine percent of centers routinely require prospective crossmatches. There was dramatic variation in the use of steroids across all centers. Sixty-five percent of centers transition adolescents to an adult program. Prophylaxis protocols were also highly inconsistent. This survey provided a comprehensive insight into current practices at pediatric heart transplant programs. The results delineated remarkably variable strategies for routine aspects of care. Analysis of divergence along with uniformity across protocols is a valuable exercise and may serve as a stepping-stone toward ongoing cooperation and clarity for evidence-based practice protocols.

Pediatric cardiac retransplant: differing patterns of primary graft failure by age at first transplant

OBJECTIVE

This study compared graft failure leading to retransplant in infants versus older children at initial heart transplant.

METHODS

Twenty-six retransplant recipients were compared by age at first transplant: infant group (<1 year) and pediatric group (≥1 year).

RESULTS

Early retransplant survival was 92%. Retransplant survivals at 1, 3, and 5 years were 83%, 74%, and 67%. There were 15 infant and 11 pediatric patients. First transplant ages were 0.4 ± 0.3 vs. 8.5 ± 5.7 years in infant and pediatric groups, respectively (P < .01). First graft rejection episodes were more common in pediatric group (4.8 ± 2.5 vs 3.1 ± 2.1, P = .032), and rejection rate was higher (1.5 ± 1.1 vs 0.4 ± 0.4, P = .0024). Median first graft survival was longer in infant group (10.7 years vs 3.9 years, P < .001). Recurrent cellular rejection was retransplant indication in 40% of infant group versus 91% of pediatric group (P < .05). Cardiac allograft vasculopathy was more prevalent in infant group (73% vs 20% in pediatric group, P = .032).

CONCLUSIONS

Infant heart transplant recipients had longer primary graft survival, fewer cellular rejection episodes, and higher incidence of cardiac allograft vasculopathy relative to older graft recipients requiring retransplant. Advantages in adaptive immunity in infant heart recipients confer improved primary graft survival, but longer graft life in these patients is limited by cardiac allograft vasculopathy. Older recipient first graft failure was rejection related, and shorter graft life probably limited development of cardiac allograft vasculopathy.