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Improved survival following pediatric cardiac transplantation in high-risk patients
Insights
Pediatric heart transplant survival has improved, with elevated transpulmonary gradient remaining a key risk factor. Advances allow successful transplantation for complex cases, including congenital heart disease and those needing extracorporeal membrane oxygenator support.
Area of Science:
- Pediatric Cardiology
- Transplantation Medicine
- Cardiovascular Surgery
Background:
- Pediatric heart transplantation faces challenges from complex congenital heart disease and elevated pulmonary vascular resistance.
- Preoperative hemodynamic support is critical for successful outcomes.
Purpose of the Study:
- To identify preoperative factors influencing survival in pediatric heart transplantation.
- To compare outcomes across two distinct eras of transplant experience.
Main Methods:
- Retrospective analysis of demographic, clinical, and hemodynamic data from 67 pediatric heart transplant recipients.
- Comparison of survival rates between an early (1982-1989) and a late (1989-1992) transplant era.
Main Results:
- In the early era, congenital heart disease, extracorporeal membrane oxygenator (ECMO) support, UNOS status I, elevated transpulmonary gradient, and elevated pulmonary vascular resistance index were risk factors for early death.
- In the late era, only elevated transpulmonary gradient remained a significant risk factor.
- Multivariate analysis identified elevated transpulmonary gradient as the sole significant risk factor across all experiences.
- One-year survival for congenital heart disease improved from 46% to 73% between eras.
- Survival for patients with pretransplant ECMO support improved significantly in the later era.
Conclusions:
- Elevated transpulmonary gradient remains a significant risk factor in pediatric heart transplantation.
- Improved outcomes are now achievable for candidates with congenital heart disease, UNOS status I, and pretransplant ECMO support.
- Pediatric heart transplant protocols have evolved to enhance survival rates for high-risk patients.
Background:
Preoperative hemodynamic support, complex congenital heart disease, and elevated pulmonary vascular resistance present particular challenges for pediatric heart transplantation. This study was performed to identify preoperative factors that influence survival after pediatric heart transplantation over two eras of pediatric heart transplant experience.
Methods And Results:
We retrospectively analyzed demographic, clinical, and hemodynamic data from 67 pediatric patients who underwent heart transplantation between February 1982 and June 1992 and compared survival between two eras (early experience versus late experience). During the early experience (group 1: February 1982 to August 1989), univariate analysis identified congenital heart disease, pretransplant extracorporeal membrane oxygenator (ECMO) support, inotropic and/or ventilatory support (UNOS status I), elevated transpulmonary gradient (at least 15 mm Hg), and elevated pulmonary vascular resistance index (at least 4 Wood units.m2) as preoperative risk factors for early death after pediatric heart transplantation. However, in the late experience (group 2: September 1989 to June 1992), the only risk factor for premature death by univariate analysis was elevated transpulmonary gradient. By multivariate analysis, elevated transpulmonary gradient was the only risk factor for our early, late, and entire experiences. One-year survival after transplantation for congenital heart disease was improved from 46% in group 1 to 73% in group 2 (P < .05). In group 1, only one patient (25%) with pretransplant ECMO support survived 1 year, whereas 66% (four of six) survived more than 1 year in group 2.
Conclusions:
Although elevated transpulmonary gradient continues to be a significant risk factor for pediatric heart transplantation, candidates with congenital heart disease, UNOS status I, and pretransplant ECMO support now can be successfully transplanted with reasonable hope for extended survival.