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Heterotopic cardiac transplantation in infants and children
A Khaghani1, F Santini, C M Dyke
1Harefield Hospital, Middlesex, United Kingdom.
Insights
Heterotopic heart transplantation offers a viable solution for children with advanced heart failure and high pulmonary vascular resistance, demonstrating good medium-term outcomes including reduced pulmonary artery pressure and normal growth.
Area of Science:
- Pediatric Cardiology
- Cardiovascular Surgery
- Transplantation Immunology
Background:
- Children with advanced heart failure and elevated pulmonary vascular resistance present complex management challenges.
- The limitations of standard donor hearts and organ availability complicate treatment for this population.
Purpose of the Study:
- To evaluate the feasibility and outcomes of heterotopic heart transplantation in pediatric patients with advanced heart failure.
- To assess the impact of this procedure on pulmonary vascular resistance and patient growth.
Main Methods:
- A cohort of 12 children (11 months to 15.2 years) underwent heterotopic heart transplantation between 1991 and 1996.
- Eight patients had significant preoperative pulmonary hypertension; donor pulmonary artery was anastomosed to the recipient right atrium.
- Immunosuppression included cyclosporine and azathioprine; steroids were not routinely used.
Main Results:
- One in-hospital death due to acute rejection; two late deaths (18.2%) from cardiac rejection.
- Nine survivors (75%) show normal growth and activity at a mean follow-up of 2.2 years.
- Pulmonary artery pressure decreased post-transplant in patients with preoperative pulmonary hypertension; recipient heart function remained stable.
Conclusions:
- Heterotopic heart transplantation is a feasible option for select pediatric heart failure patients.
- The procedure yields good medium-term results, including regression of pulmonary artery pressure and normal growth.
- This approach avoids long-term chest complications and addresses donor organ size limitations.
Background:
Children with advanced heart failure, particularly those with elevated pulmonary vascular resistance, pose a difficult management problem because the normal donor right ventricle cannot cope with the high pulmonary resistance and because of the relative shortage of donor organs of an appropriate size for this age group.
Methods:
In an attempt to address these issues and evaluate the role of heterotopic transplantation in this context, we operated on 12 children, six boys and six girls, in the period between January 1, 1991, and March 31, 1996. Their ages ranged from 11 months to 15.2 years (mean 81.6 +/- 62.8 months) and their mean weight was 23.3 kg (range 7.6 to 56.8 kg). Eight patients (66.6%) had significant elevation of pulmonary artery pressure (pulmonary artery systolic pressure = 66 +/- 9.4 mm Hg, mean transpulmonary gradient = 22.3 +/- 3.4 mm Hg). In all patients the donor pulmonary artery was anastomosed to the recipient right atrium without the use of any prosthetic material. Ischemic times varied between 135 and 255 minutes (mean 182.1 +/- 30.7 minutes). The immunosuppression regimen included cyclosporine and azathioprine. Steroids were not routinely used.
Results:
One patient died in the hospital of acute rejection on postoperative day 16. Three patients had lobe collapse within 1 week and all were treated successfully. Two late deaths (18.2%) occurred as a result of cardiac rejection 3 months and 2 years after the operations. Nine survivors (75%) are alive, active, and growing normally at a mean follow-up of 2.2 years (range 11 months to 4.75 years). Repeated cardiac catheterization performed in seven patients with preoperative pulmonary hypertension showed a slow progressive drop in mean pulmonary artery pressure. No significant change was observed in the function of the recipient hearts.
Conclusion:
We conclude that heterotopic heart transplantation is feasible for a selected group of children with good medium-term results, notably regression of pulmonary artery pressure, normal growth, and lack of long-term chest complications.