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Pediatric heart transplantation: Looking forward after five decades of learning
Anne I Dipchand1, Steven A Webber2
1Department of Paediatrics, Head, Heart Transplant, Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
Insights
Pediatric heart transplantation survival has improved, but chronic allograft vasculopathy (CAV) remains a key challenge. Future efforts focus on donor utilization, non-invasive rejection biomarkers, and CAV prevention.
Area of Science:
- Cardiology
- Transplantation Medicine
- Pediatric Health
Background:
- Pediatric heart transplantation is a standard treatment for end-stage heart disease.
- Over 13,000 pediatric heart transplants were reported to ISHLT between 1992 and 2018.
- Short-term outcomes have significantly improved, with excellent long-term survival for 1-year survivors.
Purpose of the Study:
- To review key observations and practice changes in pediatric heart transplantation.
- To highlight lessons learned and advancements in the field over five decades.
- To identify future challenges and research directions in pediatric heart transplantation.
Main Methods:
- Review of historical data and outcomes from The International Society of Heart and Lung Transplant (ISHLT).
- Analysis of survival rates, causes of graft loss, and post-transplant complications.
- Discussion of current challenges and potential future strategies.
Main Results:
- Excellent long-term survival (over 60% at 25 years) for infant recipients surviving the first year.
- Chronic allograft vasculopathy (CAV) is a primary driver of graft loss beyond the first year.
- Acute rejection, CAV, graft failure, and infection are major causes of death within five years.
Conclusions:
- Despite improved survival, preventing CAV and managing long-term immunosuppression effects are critical.
- Future research should focus on improving donor organ utilization and developing non-invasive rejection biomarkers.
- Addressing renal dysfunction, malignancy, and re-transplantation needs is essential for long-term pediatric heart transplant success.
Abstract:
Heart transplantation has become the standard of care for pediatric patients with end-stage heart disease throughout the world. Since the first transplant was performed in 1967, the number of transplants has grown dramatically with 13 449 pediatric heart transplants being reported to The International Society of Heart and Lung Transplant (ISHLT) between January 1992 and June 30, 2018. Outcomes have consistently improved over the last few decades, specifically short-term outcomes. Most recent survival data demonstrate that recipients who survive to 1-year post-transplant have excellent long-term survival with more than 60% of those who were transplanted as infants being alive 25 years later. Nonetheless, the rates of graft loss beyond the first year have remained relatively constant over time; driven primarily by our poor understanding and lack of treatments for chronic allograft vasculopathy (CAV). Acute rejection, CAV, graft failure, and infection continue to be the major causes of death within the first 5 years post-transplant. In addition, renal dysfunction, malignancy, and the need for re-transplantation remain as significant issues that require close follow-up. Looking forward, key challenges include improving donor utilization rates (including donation after cardiac death (DCD) and the use of ex vivo perfusion devices), the development of non-invasive biomarkers for rejection, efforts to mitigate the long-term effects of immunosuppression, and prevention of CAV. It is not possible to cover the entire evolution of pediatric heart transplantation over the last five decades, but in this review, we hope to touch on key observations, lessons learned, and practice changes that have advanced the field, as well as glance ahead to the next decade.
