Heart transplantation in pediatric oncology patients

Advances in pediatric oncology have dramatically improved survival, leading to a growing population of childhood cancer survivors (CCS). However, many of these individuals are at risk for late cardiac complications from cancer therapy. A known complication coined cancer therapy-related cardiac dysfunction (CTRCD) can progress to end-stage heart failure. This review examines the evolving role of heart transplantation in CCS with advanced heart failure, including, addressing patient selection, clinical outcomes, and unique management considerations. CTRCD most often results from anthracycline chemotherapy and chest radiation. Newer therapies have emerged to improve survival and include immunotherapy and targeted agents. These newer agents also pose cardiotoxic risks. CTRCD is often irreversible and progressive; it is imperative that such damage be prevented with strategies such as limiting cumulative anthracycline exposures, utilizing anthracycline-sparing regimens when feasible, and increasing the use of cardioprotective agents like dexrazoxane. With refractory heart failure, mechanical circulatory support and heart transplantation may be appropriate, though the decision making requires a multidisciplinary collaboration. Although CCS present unique challenges-such as immunosuppression risks, and elevated infection or secondary cancer risk-current data demonstrate comparable post-transplant survival to non-oncology patients. Heart transplantation is a viable and effective treatment for select CCS with end-stage heart failure. Careful multidisciplinary evaluation, tailored immunosuppression, and vigilant long-term surveillance are essential to optimize outcomes in this complex population.