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Heart- and heart-lung transplantation in children
P R Vouhé1, J Le Bidois, P Dartevelle
1Service de Chirurgie Cardiaque, Laënnec Hospital, Paris, France.
Insights
Pediatric heart and heart-lung transplants show promising outcomes, with minimal late complications in survivors. Long-term effects of immunosuppression require further investigation.
Area of Science:
- Pediatric Cardiology
- Thoracic Surgery
- Immunosuppression Therapy
Background:
- End-stage cardiac and pulmonary diseases in children necessitate advanced treatment options.
- Heart transplantation (HTX) and heart-lung transplantation (HLTX) offer potential solutions for pediatric patients.
- Optimizing immunosuppression protocols is crucial for long-term graft survival and patient well-being.
Purpose of the Study:
- To evaluate the early and late outcomes of heart and heart-lung transplantation in prepubertal children.
- To assess the safety and efficacy of a steroid-sparing immunosuppression regimen.
- To identify complications and growth patterns in pediatric transplant recipients.
Main Methods:
- Retrospective analysis of 16 prepubertal children undergoing HTX (13) or HLTX (3) since January 1987.
- Immunosuppression primarily consisted of cyclosporine and azathioprine, with steroids reserved for rejection episodes.
- Patient data including indications, complications, graft survival, growth, and renal function were reviewed.
Main Results:
- Overall survival was 75% for HTX and 33% for HLTX within the follow-up period.
- Early mortality was associated with graft failure, pulmonary hypertension, and infection.
- Survivors of HTX experienced minimal late complications, including rare rejection episodes, normal growth, and preserved renal function, despite mild tubulointerstitial lesions.
Conclusions:
- Heart transplantation in children demonstrates favorable short-term outcomes with a steroid-sparing immunosuppression strategy.
- Heart-lung transplantation in this cohort faced significant early challenges, including rejection and infection.
- While promising, the long-term efficacy and safety of these procedures, particularly the impact of cyclosporine, warrant continued investigation.
Abstract:
Since January 1987, 16 prepubertal children have undergone heart (13) or heart-lung (3) transplantation. Immunosuppression included cyclosporine and azathioprine and excluded steroids except in case of rejection. The indications for heart transplantation were hypoplastic left heart syndrome (4 infants, mean age = 2 months), congenital heart disease (4 patients, mean age = 5.7 years) and cardiomyopathy (5 patients, mean age = 2.8 years). There were 4 early deaths (acute graft failure in 2, pulmonary hypertension in 1, infection in 1) and 1 late death (heart failure at 3 months). The 8 survivors had a mean follow-up of 12 months (range 1-19 months). Late complications were minimal. There were 4 episodes of rejection in 2 patients. There was no infection, normal somatic growth and no systemic hypertension. Renal function remained within normal limits although mild-to-moderate tubulointerstitial lesions were found in 4 renal biopsies. Three children (9-11 years old) underwent heart-lung transplantation. The early postoperative course was difficult with 6 episodes of rejection and 5 infections. One patient died at 3 months from infectious complications. One child has a complete rehabilitation 8 months posttransplantation. The last patient is clinically well at 7 months but has a residual tracheal stenosis. The long-term fate of these children, and particularly the long-term effects of cyclosporine therapy are unknown. Heart and heart-lung transplantation remain under investigation but may be reasonable approaches for infants and children with end-stage cardiac and/or pulmonary disease.