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Waiting before birth: outcomes after fetal listing for heart transplantation
S M Pollock-Barziv1, B W McCrindle, L J West
1The Hospital for Sick Children, Labatt Family Heart Centre, Heart Transplant Program, The University of Toronto, Toronto, Ontario, Canada.
Insights
Fetal listing for heart transplantation (HTx) offers an alternative to termination or surgery for severe heart defects. This approach provides a wider window for organ availability, showing fair outcomes and low wait-list mortality.
Area of Science:
- Pediatric Cardiology
- Transplant Surgery
- Fetal Medicine
Background:
- Fetal diagnosis of severe heart defects presents difficult decisions regarding pregnancy termination, neonatal surgical palliation, or heart transplantation (HTx).
- Fetal listing for HTx is a strategy to potentially increase the window for donor organ availability.
Purpose of the Study:
- To describe the outcomes of patients listed for heart transplantation while still in utero.
- To evaluate the feasibility and effectiveness of fetal cardiac transplantation.
Main Methods:
- Retrospective review of cardiac and transplant databases from 1990 to July 2006.
- Identification and analysis of all fetal listings for heart transplantation during the study period.
Main Results:
- Twenty-six fetal listings were identified, primarily for congenital heart disease (n=24).
- Eighteen patients underwent heart transplantation, with a median wait-list time of 19 days in utero and 22 days postnatally.
- Wait-list mortality was low, with one stillbirth; seven patients were delisted post-birth for surgical palliation or clinical improvement.
Conclusions:
- Fetal listing for heart transplantation is a viable option for selected cases, expanding donor organ access.
- Patients undergoing fetal listing demonstrated low wait-list mortality and fair intermediate-term outcomes.
- Establishing clear eligibility criteria and prioritizing infants over fetuses for organ allocation are recommended for centers offering fetal listing.
Abstract:
Following fetal diagnosis of a profound heart defect, transplantation (HTx) is an alternative to pregnancy termination or neonatal surgical palliation. Retrospective review of the cardiac and transplant databases of fetal listings for HTx between 1990 and July 2006 was undertaken to describe outcomes after listing. We identified 26 fetal listings (of 269 total listings). Diagnoses included congenital heart disease (n = 24) and cardiomyopathy (n = 2). Seven patients were delisted after birth: in five cases parents opted for surgical palliation, two clinically improved. One patient died wait-listed (stillborn). Time wait-listed as a fetus ranged from 1-41 days (median 19 days). Eighteen patients underwent HTx (median weight 2.8 kg, range 2.1-10.9 kg); median days wait-listed after birth was 22 (4 h-123 days). Two fetuses were surgically delivered at 36 weeks gestation when a donor organ became available; 11 were transplanted as neonates (<30 days). The median age at HTx was 1 month (4 h-2.6 months). Fetal listing for HTx increases the potential window of opportunity for a donor organ to become available; patients had low wait-list mortality and a fair intermediate-term outcome. Well-defined criteria for eligibility for fetal listing and priority allocation to infants over fetuses seem rational approaches for centers that offer fetal listing.
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