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The evolution of pediatric heart retransplantation over three decades: An analysis from the PHTS
Maria Del Carmen Vazquez Alvarez1, Ryan Cantor2, Devin Koehl2
1Labatt Family Heart Center, Hospital for the Sick Children, Toronto, Ontario, Canada.
Insights
Pediatric heart retransplantation outcomes have improved, offering a viable option for select patients. However, retransplantation should be avoided in cases of early graft failure, particularly those requiring mechanical support.
Area of Science:
- Pediatric Cardiology
- Transplantation Medicine
- Immunology
Background:
- Pediatric retransplantation is uncommon and linked to poorer survival and increased morbidity.
- Understanding trends and patient selection in pediatric retransplants is crucial for improving outcomes.
Purpose of the Study:
- To analyze an updated cohort of pediatric heart retransplants.
- To assess for an era effect on retransplant outcomes.
- To determine if patient selection changes explain observed trends.
Main Methods:
- Analysis of the Pediatric Heart Transplant Society database for pediatric retransplantation patients (<18 years).
- Data divided into three eras: 1993-2001, 2002-2010, and 2011-2018.
- Multivariate and multiphase parametric hazard modeling to identify risk factors and era effects on graft loss.
Main Results:
- Retransplantation survival (median 9.3 years) was lower than primary transplantation (median 20.2 years).
- Median survival improved from Era 1 to Era 2 but plateaued in Era 3.
- Factors predicting graft loss included early transplant era, congenital heart disease, short inter-transplant interval, and mechanical support (VAD/ECMO).
- Longer inter-transplant intervals correlated with decreased graft loss risk.
Conclusions:
- Pediatric heart retransplantation survival has improved, making it a viable option for carefully selected patients.
- Retransplantation is strongly discouraged in early graft failure cases, especially those requiring mechanical circulatory support.
Background:
Retransplantation is rare and associated with worse survival and more morbidity. The study aim is to describe an updated cohort of pediatric retransplants, determine if there has been an era effect on outcomes, and understand if identified trends are explained by changes in patient selection.
Methods:
Pediatric Heart Transplant Society database analysis of retransplantation patients <18 years of age (Era 1: 1993-2001, Era 2: 2002-2010, Era 3: 2011-2018). Multivariate analysis identified risk factors for graft loss. Multiphase parametric hazard modeling was used to depict era and risk factor effect.
Results:
Survival was lower (p < .0001) for retransplant (n = 222) compared to primary transplant (n = 6548) (median 9.3 vs 20.2 years). Median survival increased from Era 1 to 2 (4.8 vs 9.3 years; p < .0001) with no incremental change in Era 3. Era 2 and 3 retransplants had a longer inter-transplant interval (p < .0001), were less frequently for early graft failure (p = .0004) or acute rejection (p = .007), more frequently from a ventricular assist device (p = .0014), and less frequently from extracorporeal membrane oxygenation (p = .0024). Predictors of graft loss included Era 1 (HR 10.55, p = .001), congenital heart disease (HR 4.42, p = .01), inter-transplant interval <1 year (HR 5.34, p = .002), and mechanical support (ventricular assist device HR 7.47, p = .0042; extracorporeal membrane oxygenation HR 10.09, p < .0001). For each 1-year increase in inter-transplant interval, graft loss risk decreased by 1.15 (p = .0002). Retransplantation was associated with more rejection, infection, and allograft vasculopathy.
Conclusions:
Graft survival has improved in pediatric retransplants making it a viable option in select patients. Retransplantation should be avoided in the setting of early graft failure especially requiring mechanical support.
