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Pediatric heart transplantation: improving results in high-risk patients
G Dellgren1, B Koirala, A Sakopoulus
1Division of Cardiovascular Surgery of The Hospital for Sick Children and University of Toronto, 555 University Ave., Toronto, Ontario M5G 1X8, Canada.
Insights
Innovative protocols for pediatric cardiac transplantation, including donor blood cardioplegia with insulin and ABO-incompatible transplants, significantly improved patient and graft survival. These advancements allow successful treatment for high-risk pediatric patients.
Area of Science:
- Cardiology
- Pediatric Surgery
- Transplantation Immunology
Background:
- Pediatric cardiac transplantation is limited by donor availability and patient selection criteria.
- Unconventional management protocols aim to expand eligibility and improve outcomes for pediatric heart recipients.
Purpose of the Study:
- To evaluate the impact of novel donor and recipient management strategies on pediatric cardiac transplantation outcomes.
- To assess the efficacy of insulin-augmented cardioplegia and ABO-incompatible heart transplantation.
Main Methods:
- Retrospective review of 73 pediatric cardiac transplantations (1990-1999).
- Analysis of outcomes with donor blood cardioplegic solution (insulin added) versus crystalloid-based procurement.
- Evaluation of ABO-incompatible transplants using plasma exchange on bypass.
- Assessment of patients requiring extracorporeal membrane oxygenator (ECMO) support.
Main Results:
- Insulin-augmented cardioplegia significantly improved survival (HR=0.25, P=.08) despite longer ischemic times.
- ABO-incompatible transplantation showed minimal reactivity and was not a risk factor for death (multivariate analysis).
- Survival after transplantation was high for patients requiring preoperative ECMO support, with 3 late deaths (HR=2.88, P=.05).
Conclusions:
- Modified surgical and medical protocols enhance pediatric cardiac transplantation success.
- These strategies enable the treatment of previously high-risk or unsuitable pediatric candidates.
- Continuous protocol improvements are leading to better outcomes in pediatric heart transplantation.
Objectives:
Our institutional experience with 73 pediatric patients undergoing cardiac transplantation between January 1, 1990, and December 31, 1999, was reviewed to determine the impact of unconventional donor and recipient management protocols implemented to extend the availability of this therapy.
Methods And Results:
The introduction of donor blood cardioplegic solution with added insulin was associated with a significant improvement in patient and graft survival (hazard ratio [Cox] = 0.25, P =.08), despite significantly longer ischemic times with this protocol compared with the use of crystalloid-based donor procurement techniques (P <.01). Eleven patients underwent intentional transplantation of ABO-incompatible donor hearts with the aid of a protocol of plasma exchange on bypass. In this subgroup, there were 2 early deaths caused by nonspecific graft failure (n = 1) and respiratory complications with mild vascular rejection (n = 1), and there was 1 late death caused by lymphoma. ABO-incompatible transplantation was not a risk factor for death by multivariate analysis. The postoperative course in these patients suggests minimal reactivity directed against incompatible grafts on the basis of low anti-donor blood group antibody production, in association with a favorable rejection profile. Ten of 13 patients requiring preoperative support with an extracorporeal membrane oxygenator survived transplantation; there were 3 additional late deaths in this subgroup (hazard ratio = 2.88, P =.05).
Conclusions:
The results with pediatric cardiac transplantation continue to improve as a result of changes in both surgical and medical protocols permitting successful treatment of patients conventionally considered at high risk or unsuitable for transplantation.