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Sudden death after pediatric heart transplantation: analysis of data from the Pediatric Heart Transplant Study Group
Kevin P Daly1, Sujata B Chakravarti, Margaret Tresler
1Department of Cardiology, Children's Hospital Boston and the Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA. kevin.daly@childrens.harvard.edu
Insights
Sudden death is a significant concern after pediatric heart transplantation, accounting for 16% of deaths. Key risk factors include black race, UNOS status 2, older age, and rejection episodes.
Area of Science:
- Pediatric Cardiology
- Transplantation Medicine
- Sudden Cardiac Death Research
Background:
- Sudden death is a known complication of heart transplantation.
- Limited data exists on sudden death incidence and risk factors in pediatric heart transplant recipients.
Purpose of the Study:
- To determine the incidence of sudden death after heart transplantation in children.
- To identify risk factors associated with sudden death in this population.
Main Methods:
- Retrospective analysis of the Pediatric Heart Transplant Study Group (PHTS) database (1993-2007).
- Inclusion criteria: children (<18 years) undergoing heart transplantation.
- Statistical analyses included Kaplan-Meier, parametric survival, and multivariate hazard-function models.
Main Results:
- Sudden death accounted for 94 (16%) of 604 deaths in 2,491 children.
- Five-year freedom from sudden death was 97%, with a constant hazard rate.
- Risk factors for sudden death: black race (HR 2.6), UNOS status 2 (HR 1.8), older age (HR 1.4/10 years), and rejection episodes (HR 1.6/episode).
Conclusions:
- Sudden death represents 1 in 6 deaths post-pediatric heart transplant.
- Identified risk factors: older recipient age, early recurrent rejection, black race, and UNOS status 2.
- Primary prevention strategies may benefit high-risk patients.
Background:
Sudden death is a well-recognized complication of heart transplantation. Little is known about the incidence and risk factors for sudden death after transplant in children. The purpose of this study was to determine the incidence of and risk factors for sudden death.
Methods:
This retrospective multicenter cohort study used the Pediatric Heart Transplant Study Group (PHTS) database, an event-driven registry of children aged <18 at listing undergoing heart transplantation between 1993 and 2007. Standard Kaplan-Meier and parametric analyses were used for survival analysis. Multivariate analysis in the hazard-function domain was used to identify risk factors for sudden death after transplant.
Results:
Of 604 deaths in 2,491 children who underwent heart transplantation, 94 (16%) were classified as sudden. Freedom from sudden death was 97% at 5 years, and the hazard for sudden death remained constant over time at 0.01 deaths/year. Multivariate risk factors associated with sudden death included black race (hazard ratio [HR], 2.6; p < 0.0001), United Network of Organ Sharing (UNOS) status 2 at transplant (HR, 1.8; p = 0.008), older age (HR, 1.4/10 years of age; p = 0.03), and an increased number of rejection episodes in the first post-transplant year (HR, 1.6/episode; p = 0.03).
Conclusion:
Sudden death accounts for 1 in 6 deaths after heart transplant in children. Older recipient age, recurrent rejection within the first year, black race, and UNOS status 2 at listing were associated with sudden death. Patients with 1 or more of these risk factors may benefit from primary prevention efforts.
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