Increasing Complexity of Heart Transplantation in Patients With Congenital Heart Disease

Owing to improved surgical results, there is a growing population of patients with repaired congenital heart disease (CHD) requiring heart transplantation. The objective of the study was to review our experience in these patients. A retrospective review of the outcomes of heart transplantation in patients with CHD (n = 77) between 1988 and 2014 was performed. Outcomes of early (1988-1999) and late (2000-2014) eras were compared. In results, the mean age was 18 ± 14 years (range: 16 days-58 years). Seventy (91%) patients underwent a mean of 2.6 ± 1.3 (range: 1-6) cardiac operations before transplantation, whereas 7 were primary transplants. Univentricular palliation had been performed in 44 (57%) patients. Patients with CHD in the later era had longer mean cardiopulmonary bypass time (early: 190 ± 70 minute vs late: 271 ± 115 minute; P < 0.001), ischemic times (early: 222 ± 98 minute vs late: 275 ± 102 minute; P = 0.039), and more often required reconstruction of the great arteries at the time of transplantation (8% vs 28%; P = 0.036). In those with prior univentricular palliations, the ratio of ischemic to cardiopulmonary bypass time decreased in the later era (early: 1.41 ± 0.60 vs late: 0.99 ± 0.37; P = 0.016), reflecting increased intraoperative complexity. Following transplantation, hospital mortality was 13% (10/77; 7 due to primary graft failure). There was no difference in inhospital mortality between the 2 eras (P = 0.52); however, patients in the later era more often required postoperative extracorporeal membrane oxygenation (early: 8%, 3/38 vs late: 28%, 11/39; P = 0.036). In patients with prior univentricular palliations, those in the late era were more likely to experience postoperative renal impairment (early: 1/21, 5% vs late: 9/23, 39%; P = 0.01). Patients with CHD had higher 30-day mortality (CHD: n = 8, 10% vs non-CHD: n = 17, 3.8%; P = 0.021), but similar survival at 10 years (67% ± 12% vs 70% ± 4.7%; P = 0.87) compared to those without CHD. In conclusion, patients with CHD undergoing cardiac transplantation in the recent era were more complex. They had a greater number of prior cardiac operations, and more often underwent complex vascular reconstructions and required more prolonged intraoperative preparation.