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Modern Outcomes of Mechanical Circulatory Support as a Bridge to Pediatric Heart Transplantation
Brody Wehman1, Kristen A Stafford2, Gregory J Bittle1
1Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland.
Insights
Pediatric heart transplant patients bridged with ventricular assist devices (VAD) show similar survival to direct transplant. Extracorporeal membrane oxygenation (ECMO) bridge is linked to worse early survival.
Area of Science:
- Pediatric Cardiology
- Cardiovascular Surgery
- Transplantation Medicine
Background:
- Pediatric heart transplantation often necessitates mechanical circulatory support as a bridge to transplantation (BTT).
- Limited large-scale data exists on post-transplant survival and mortality predictors in pediatric patients requiring BTT in the modern era.
Purpose of the Study:
- To analyze post-transplant survival outcomes in pediatric heart transplant recipients based on their bridge to transplantation strategy.
- To identify predictors of mortality in pediatric heart transplant patients supported by mechanical circulatory support.
Main Methods:
- Utilized the United Network for Organ Sharing database for pediatric heart transplant recipients from 2005-2012.
- Stratified patients into three groups: extracorporeal membrane oxygenation (ECMO) bridge to transplantation (BTT), ventricular assist device (VAD) BTT, and direct transplantation (DTXP).
- Primary outcome was post-transplant survival, with survival analysis performed at various time points and multivariable analysis for mortality predictors.
Main Results:
- Out of 2,777 pediatric heart transplants, 617 (22.2%) required BTT (428 VAD, 189 ECMO).
- VAD use increased during the study period. ECMO BTT patients were younger and smaller than DTXP, while VAD BTT patients were older and larger.
- Actuarial survival was similar between VAD BTT and DTXP groups, but lower for ECMO BTT. This difference diminished after censoring the first 4 months post-transplant.
- Multivariable analysis identified ECMO BTT, younger age, specific diagnoses, and poorer functional status as independent predictors of early mortality (within 4 months).
Conclusions:
- Pediatric heart transplant recipients undergoing direct transplantation (DTXP) or utilizing a ventricular assist device (VAD) as a bridge to transplantation (BTT) demonstrate comparable post-transplant survival.
- Patients requiring extracorporeal membrane oxygenation (ECMO) as a bridge to transplantation experience significantly inferior early post-transplant survival compared to those undergoing direct transplantation.
Background:
Pediatric patients awaiting orthotopic heart transplantation frequently require bridge to transplantation (BTT) with mechanical circulatory support. Posttransplant survival outcomes and predictors of mortality have not been thoroughly described in the modern era using a large-scale analysis.
Methods:
The United Network for Organ Sharing database was reviewed to identify pediatric heart transplant recipients from 2005 through 2012. Patients were stratified into three groups: extracorporeal membrane oxygenation (ECMO), ventricular assist device (VAD), and direct transplantation (DTXP). The primary outcome was posttransplant survival.
Results:
Two thousand seven hundred seventy-seven pediatric patients underwent orthotopic heart transplantation. There were 617 patients who required BTT with mechanical circulatory support (22.2%), of whom there were 428 VAD BTT (69.4%) and 189 ECMO BTT (30.6%). An increase in VAD use was observed during the study period (p < 0.0001). Compared with DTXP, patients in the ECMO BTT group had a lower median age (<1 versus 5 years; p < 0.0001) and were significantly smaller (8 versus 14 kg; p < 0.001), whereas patients in the VAD BTT group were older (8 versus 5 years; p = 0.0002) and larger (24 versus 14 kg; p < 0.001). Actuarial survival was greater in the DTXP group compared with ECMO BTT, but similar to VAD BTT at 30 days and 1, 3, and 5 years. However, this survival difference was lost after censoring the first 4 months after transplant. In multivariable analysis, when restricted to the first 4 months of survival, independent predictors for mortality were ECMO BTT, age, diagnosis, and functional status, whereas VAD BTT was not.
Conclusions:
Pediatric patients with DTXP or VAD BTT have equivalent posttransplant survival. However, those requiring ECMO BTT have inferior early posttransplant survival compared with those receiving DTXP.
