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Published on: June 26, 2020
Infant heart transplantation: improved intermediate results
M B Mitchell1, D N Campbell, D R Clarke
1The Department of Surgery, University of Colorado Health Sciences Center and the Children's Hospital, Denver 80262, USA.
Insights
Heart transplantation in infants shows improving outcomes with experience. Prior sternotomy is a key risk factor for early infant heart transplant mortality, but survival rates are excellent.
Area of Science:
- Pediatric Cardiology
- Cardiothoracic Surgery
- Transplant Medicine
Background:
- Infant heart transplantation is a complex procedure with significant early mortality risks.
- Prior surgical history, such as sternotomy, may impact outcomes in infant heart transplantation.
- Experience and evolving surgical techniques can influence the success rates of infant heart transplants.
Purpose of the Study:
- To review the center's experience with heart transplantation in infants under six months of age.
- To identify risk factors associated with 30-day mortality following infant heart transplantation.
- To compare outcomes between the early and recent phases of the study period.
Main Methods:
- Analysis of infant heart transplant recipients listed before September 1996.
- Comparison of early versus recent halves of the patient cohort.
- Univariate and multivariable analyses to identify risk factors for 30-day mortality.
- Kaplan-Meier survival analysis and log-rank testing for survival comparisons.
Main Results:
- Overall 30-day mortality was 18%, with a significant decrease from 30% in the early period to 10% in the recent period (p=0.07).
- Prior sternotomy (p=0.01) was identified as an independent risk factor for 30-day mortality.
- Actuarial survival rates at 1, 2, and 3 years were 80%, 78%, and 70%, respectively, showing improvement over time (p=0.05).
Conclusions:
- Infant heart transplant outcomes have improved with accumulated surgical experience.
- Prior sternotomy is a significant risk factor that increases early mortality.
- Intermediate-term survival for infants undergoing heart transplantation for end-stage heart disease is favorable.
Objectives:
Our objectives were to (1) review our experience with heart transplants in infants (age < 6 months), (2) delineate risk factors for 30-day mortality, and (3) compare outcomes between our early and recent experience.
Methods:
Records of all infants listed for transplantation in our center before September 1996 were analyzed. Early and recent comparisons were made between chronologic halves of the accrual period. Univariate analysis was used to analyze potential risk factors for 30-day mortality (categorical variables, Fisher's exact test; continuous variables, nonparametric Wilcoxon rank-sum test). Multivariable analysis included univariate variables with p values < or = 0.10. Actuarial survivals were estimated (Kaplan-Meier) and compared by the log-rank test.
Results:
Fifty-one of the 60 infants listed for transplantation were operated on (waiting list mortality 15%). Thirty-day mortality was 18% overall, 30% in the first 3 years and 10% in the last 3 years (p = 0.07). Sepsis was the commonest cause of early death (4/9). Univariate analysis suggested four potential risk factors for early death: preoperative mechanical ventilation (p = 0.01), prior sternotomy (p = 0.002), preoperative inotropic drugs (p = 0.08), and warm ischemia time (p = 0.08). Multivariable analysis indicated that prior sternotomy (p = 0.01) was an independent risk factor for 30-day mortality. Actuarial survivals were 80%, 78%, and 70% at 1, 2, and 3 years, and these figures improved between early and recent groups (p = 0.05). Late deaths were most commonly due to acute rejection (3/5).
Conclusions:
Results of heart transplantation in infancy improve with experience. Prior sternotomy increases initial risk. Intermediate-term survival for infants with end-stage heart disease is excellent.
