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Pediatric heart transplantation
Robert J Boucek1, Mark M Boucek
1All Children's Hospital, University of South Florida, St. Petersburg, Florida, 33701, USA. boucekr@allkids.org
Insights
Pediatric heart transplantation offers good outcomes for children with severe heart conditions, improving survival rates and quality of life. Ongoing research aims to further reduce late mortality and enhance long-term graft survival for decades-long success.
Area of Science:
- Pediatric Cardiology
- Transplant Medicine
- Immunology
Background:
- Heart transplantation is a viable treatment for infants and children with end-stage heart failure or complex congenital heart defects.
- Current one-year and five-year survival rates are approximately 75% and 65%, respectively, with a patient survival half-life exceeding 10 years.
Purpose of the Study:
- To review the current status and outcomes of pediatric heart transplantation.
- To identify areas for improvement in reducing late mortality and enhancing long-term graft survival.
- To discuss the quality of life and long-term management considerations for pediatric heart recipients.
Main Methods:
- Review of existing literature and survival data for pediatric heart transplantation.
- Analysis of factors influencing early and late mortality.
- Discussion of current immunosuppressive strategies and emerging immunologic insights.
Main Results:
- High survival rates are achieved, with ongoing improvements attributed to reduced early mortality.
- Surviving children generally experience a normal quality of life, though somatic growth may be affected.
- 85% of infant recipients evaluated at age 6+ were in age-appropriate grades, indicating good neurocognitive outcomes.
Conclusions:
- Pediatric heart transplantation provides a significantly improved quality and duration of life for eligible children.
- Further research is needed to address late mortality causes like graft coronary artery disease and rejection.
- Optimizing immunosuppression and understanding age-dependent factors are crucial for achieving decades-long graft survival and potential graft-specific tolerance.
Abstract:
Heart transplantation is now a treatment option with good outcome for infants and children with end-stage heart failure or complex, inoperable congenital cardiac defects. One-year and 5-year actuarial survival rates are high, approximately 75% and 65%, respectively, with overall patient survival half-life greater than 10 years. To date, survival has been improving as a result of reducing early mortality. Further reductions in late mortality, in part because of graft coronary artery disease and rejection, will allow achievement of the goal of decades-long survival. Quality of life in surviving children, as judged by activity, is usually "normal." Somatic growth is usually at the low normal range but linear growth can be reduced. Of infant recipients, 85% evaluated at 6 years of age or older were in an age-appropriate grade level. Long-term management of childhood heart recipients requires the collaboration of transplant physicians, given the increasing number of immunosuppressive agents and the balance between rejection and infection. Currently, recipients are maintained on immunosuppressive medications that target calcineurin (eg, cyclosporine, tacrolimus), lymphocyte proliferation (eg, azathioprine, mycophenolate mofetil [MMF], sirolimus) and, in some instances antiinflammatory corticosteroids. Emerging evidence now suggests a favorable immunologic opportunity for transplantation in childhood and, conversely, a higher mortality rate in children who have had prior cardiac surgery. Further studies are needed to define age-dependent factors that are likely to play a role in graft survival and possible graft-specific tolerance (eg, optimal conditions for tolerance induction and how immunosuppressive regimens should be changed with maturation of the immune system). As late outcomes continue to improve, the need for donor organs likely will increase, as transplantation affords a better quality and duration of life for children with complex congenital heart disease, otherwise facing a future of multiple palliative operations and chronic heart failure.