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Pediatric heart-lung transplantation: A contemporary analysis of outcomes
Kyle W Riggs1,2, Jacquelyn L Chapman1, Marc Schecter1
1Heart Institute, Cincinnati Children's Hospital, Cincinnati, Ohio.
Insights
Pediatric heart-lung transplantation (HLT) outcomes are analyzed, revealing risk factors for waitlist and post-transplant mortality. While HLT on ECMO is risky, selected pediatric patients show considerable survival rates.
Area of Science:
- Cardiology
- Pediatric Surgery
- Transplantation Medicine
Background:
- Pediatric heart-lung transplantation (HLT) is a rare procedure.
- Limited data exists on pediatric HLT patient outcomes from the time of listing.
- This study analyzes risk factors for waitlist and post-transplant mortality in pediatric HLT candidates.
Purpose of the Study:
- To identify risk factors associated with waitlist mortality in pediatric HLT candidates.
- To determine risk factors for mortality after pediatric HLT.
- To evaluate trends and outcomes in pediatric HLT across different eras.
Main Methods:
- Utilized the UNOS database to identify 573 pediatric HLT candidates (<18 years).
- Grouped candidates by age, era, and diagnosis (primary pulmonary hypertension, congenital heart disease with/without Eisenmenger's syndrome, other).
- Employed logistic regression and Cox proportional hazard modeling to identify risk factors for waitlist and post-transplant mortality.
Main Results:
- 37% of candidates were transplanted, 42% died waiting, 7% recovered, and 15% were removed.
- Waitlist mortality risk factors included diagnoses other than CHD with ES, IV inotropic support, and infants.
- Post-transplant mortality risk factors included ECMO support, and being an infant or 1-11 years old. ECMO patients had a 2-year mortality rate of 87%.
Conclusions:
- Pediatric HLT numbers are decreasing, with HLT on ECMO appearing ineffective.
- Well-selected pediatric HLT candidates can achieve considerable post-transplant survival.
- Excluding ECMO, recent era non-infant patients with primary pulmonary hypertension demonstrated improved survival rates.
Background:
Pediatric heart-lung transplantation (HLT) is rare, and no report has analyzed patient outcomes since time of listing. We analyzed pediatric HLTs to understand risk factors for waitlist and post-HLT mortality.
Methods:
All pediatric (<18 year old) HLT candidates were identified within the UNOS database (n = 573) and grouped by age, era, and by diagnosis. Logistical regression and Cox proportional hazard modeling identified risk factors for 6-month WL and overall post-transplant mortality.
Results:
209/573 (37%) HLT candidates were transplanted, 7% recovered, 42% died waiting, and 15% were removed for another/unknown reason. Diagnoses were primary pulmonary hypertension(n = 130), congenital heart disease(CHD) without Eisenmenger's syndrome (ES) (n = 65), CHD with ES (n = 73), and other (n = 305). Patients with a diagnosis other than CHD with ES (OR: 7.55, P = .001), on IV inotropic support (OR: 2.79, P < .001), and infants (OR: 2.20, P = .004) were associated with waitlist mortality. There has been a 56% reduction in HLTs across eras (Era 1:10.8/yr vs Era 2:4.7/yr). Risk factors for post-transplant mortality were ECMO (HR: 4.1, P = .016), and being infant (HR: 2.2, P = .04) or 1-11 years old (HR: 1.78, P = .015). ECMO patients have an 87% 2-year mortality rate with a median post-transplant survival of 64 days. Overall, post-transplant survival was unchanged (log-rank P = .067) between eras. Excluding ECMO patients, in the recent era 29 non-infant patients with primary pulmonary hypertension had 93% 1-year survival and 67% 5-year survival.
Conclusions:
Nearly 600 pediatric patients have been listed for HLT in UNOS, although numbers are decreasing in the current era. HLT for a patient on ECMO appears to be an ineffective strategy; however, in well-selected cohorts, HLT can provide considerable post-transplant survival.
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