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Heart transplantation in children with a Fontan procedure
Kirk R Kanter1, William T Mahle, Robert N Vincent
1Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia 30322, USA. kkanter@emory.edu
Insights
Pediatric heart transplantation outcomes are similar for children with a prior Fontan procedure compared to those without. Careful selection ensures comparable survival rates after heart transplant for Fontan patients.
Area of Science:
- Pediatric Cardiology
- Transplant Surgery
- Congenital Heart Disease
Background:
- Previous studies suggest decreased survival in children post-Fontan procedure undergoing heart transplantation.
- This study investigates outcomes of pediatric heart transplantation in patients with a history of the Fontan procedure.
Purpose of the Study:
- To evaluate the impact of a prior Fontan procedure on primary pediatric heart transplantation outcomes.
- To compare survival rates, rejection incidence, and retransplantation rates between Fontan and non-Fontan pediatric heart transplant recipients.
Main Methods:
- Retrospective analysis of 190 primary pediatric heart transplants performed since 1988.
- Comparison of 27 Fontan patients with 163 non-Fontan patients regarding demographics, pre-transplant status, and peri-operative factors.
- Assessment of donor ischemic times, cardiopulmonary bypass times, ventilator support, and hospital stay.
Main Results:
- Fontan patients had longer donor ischemic times and cardiopulmonary bypass times, requiring more complex procedures.
- One-year and five-year actuarial survival rates were similar between Fontan (81.5%, 65.5%) and non-Fontan (84.6%, 66.2%) groups.
- Retransplantation rates were also comparable between the two groups (18.5% vs 11.0%).
Conclusions:
- Contrary to previous findings, no early or midterm disadvantage was observed for pediatric heart transplantation after a Fontan procedure.
- Carefully selected children with failing Fontan circulation can achieve similar outcomes to other heart transplant recipients.
Background:
Previous studies have reported that children with a prior Fontan procedure have decreased survival after heart transplantation. We examined 190 primary pediatric heart transplants.
Methods:
Since 1988, 27 (14.2%) of 190 children less than 18 years old undergoing primary heart transplantation had a Fontan procedure 3.7 ± 4.3 years before transplantation. Compared with 163 (85.8%) non-Fontan primary transplants, the Fontan patients were similar in age (8.2 ± 5.0 vs 6.5 ± 6.0 years), presensitization, and pretransplant clinical status. More Fontan patients had prior operations (100% vs 50%; p < 0.0001) and needed pulmonary artery reconstruction (100% vs 23.5%; p < 0.0001). Twelve (44%) had protein-losing enteropathy.
Results:
Donor ischemic times (211 ± 72 vs 170 ± 61 minutes; p = 0.0018) and cardiopulmonary bypass times (197 ± 91 vs 121 ± 53 minutes; p < 0.0001) were greater in the Fontan group as were durations of ventilator support (4.9 ± 6.6 vs 2.6 ± 3.9 days; p = 0.018) and hospital stay (20.2 ± 17.5 vs 14.3 ± 12.4 days; p = 0.0435). The Fontan group had one 30-day mortality. One-year actuarial survival (81.5% vs 84.6%, Fontan vs non-Fontan) and five-year actuarial survival (65.5% vs 66.2%, Fontan vs non-Fontan) were similar, as was rejection incidence at one year (2.0 ± 2.0 vs 1.7 ± 1.9 episodes per patient; p = 0.3972). Five Fontan patients (18.5%) required retransplantation 4.9 ± 3.6 years posttransplant compared with 18 non-Fontan patients (11.0%) retransplanted 5.2 ± 3.4 years posttransplant (p = 0.3346).
Conclusions:
Contrary to prior reports, we did not identify any early or midterm disadvantage for children undergoing heart transplantation after a previous Fontan procedure despite more complex transplant operations. We contend that carefully selected children with a failing Fontan circulation can do as well as other children with heart transplantation.
