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Optimal timing of pediatric heart transplantation
L J Addonizio1, D T Hsu, L Fuzesi
1Department of Surgery, Columbia University, College of Physicians and Surgeons, New York, New York.
Insights
Pediatric heart transplantation outcomes improve when patients avoid pulmonary hypertension and hemodynamic decompensation. Combined preoperative pulmonary hypertension and hemodynamic decompensation significantly predict mortality in pediatric heart transplant recipients.
Area of Science:
- Pediatric Cardiology
- Transplantation Medicine
- Critical Care Medicine
Background:
- Heart transplantation (HT) in children is often viewed as a last resort.
- Many pediatric HT candidates present with significant comorbidities.
- Pulmonary hypertension (PH) and hemodynamic decompensation (HD) are common in pediatric HT recipients.
Purpose of the Study:
- To retrospectively analyze the impact of preoperative PH and HD on pediatric heart transplant survival.
- To identify preoperative risk factors affecting survival in pediatric heart transplant recipients.
- To evaluate the combined effect of PH and HD on post-transplant outcomes.
Main Methods:
- Retrospective review of 30 pediatric patients undergoing HT (age 5 days to 18 years).
- Cox proportional-hazards analysis of nine potential risk factors, including PH and HD.
- Assessment of one-year actuarial survival rates based on preoperative conditions.
Main Results:
- Overall one-year survival was 66%.
- Patients without PH or HD had 100% one-year survival.
- The combined presence of PH and HD was a highly significant predictor of mortality (RR 4.08, p<0.002), with 30% survival compared to 84% in those without.
Conclusions:
- Preoperative PH and HD are critical factors influencing pediatric heart transplant outcomes.
- Avoiding PH and HD pre-transplant is associated with significantly improved survival.
- These findings highlight the importance of managing PH and HD in pediatric end-stage heart disease to optimize HT candidacy and outcomes.
Abstract:
Despite success in adults, heart transplantation (HT) is still considered by many as only desperation therapy for children with end-stage heart disease. Thus, of 30 pediatric patients undergoing HT at our center, only seven (23%) patients had not developed pulmonary hypertension with increased pulmonary vascular resistance (PH) or hemodynamic decompensation (HD) requiring inotropic support at the time of transplantation. We have retrospectively reviewed the effect of preoperative PH, HD, and seven other potential risk factors on survival of our pediatric heart transplant recipients. All 30 patients, aged 5 days to 18 years, had New York Heart Association class III or IV symptoms. Twenty had idiopathic cardiomyopathy, nine had congenital lesions, and one infant had a large left ventricular tumor. A univariate and multivariate Cox proportional-hazards analysis was performed examining the effects of nine variables on survival after transplantation: PH, HD, age, need for hospitalization, congenital heart disease, need for surgical pulmonary artery reconstruction, prior stroke, history of cardiac arrest(s), and mechanical ventilator dependence. One-year actuarial survival for the entire series was 66% and was 100% for the seven patients with neither PH nor HD. None of the nine potential risk factors was a statistically significant predictor of risk, yet the combined presence of PH and HD represented a highly significant predictor of mortality (relative risk, 4.08: 1; p less than 0.002). One-year actuarial survival of the 10 patients with this combination was 30% versus 84% of those without the combination.(ABSTRACT TRUNCATED AT 250 WORDS)