Results of Pediatric Cardiac Transplantation - Long-Term Results of a 15-Year Experience

Abstract

Introduction: Heart transplantation (HTx) has increasingly become a therapeutic option for end-stage heart failure of any origin in children. Short- and mid-term results are promising. However, long-term outcome has been a matter of concern because of acute or chronic rejection and side effects of immunosuppression. We performed a retrospective study of up to 15-years of follow-up on this patient entity. Methods: Between 1988 and 2004, 58 HTx were performed in 55 children (cardiomyopathy (DCM) 32, congenital heart disease (CHD) 23, Re-HTx 3). Mean age was 9.1 ± 7.2 years (4 days - 17.9 years). Twenty-nine patients had a total of 51 previous operations. Results: Operative mortality was 4/58 (6.8 %) due to primary graft failure. Late mortality was 7/54 (12.1 %) due to acute rejection (2), pneumonia (2), intracranial hemorrhage (1), suicide (1) and lymphoma (1). Mean follow-up was 5.2 ± 4.2 years. One-, 5-, and 10-year survival was 86 %, 80 % and 80 %, respectively, and improved significantly after 1995 (92 % and 92 %; p = 0.04). Survival was comparable for DCM and CHD patients (1-year: 88 % vs. 82 %; p = 0.19; 5-years: 84 % vs. 77 %; p = 0.12). Three patients with therapy resistant rejection and assisted circulation required retransplantation and are alive. Freedom from acute rejection was 46 % with primary cyclosporine immunosuppression and 63 % with tacrolimus. Ninety-eight percent of the survivors are at home and in excellent cardiac condition. Conclusion: Pediatric heart transplantation is a curative treatment for DCM and CHD with excellent clinical mid-term results. However, further follow-up is necessary to evaluate long-term side effects of immunosuppressants. Donor shortage remains a problem.

Key words

Pediatric - cardiac transplantation - congenital heart disease - cardiomyopathy - complication of surgery

References

• 1 Bailey L L. Role of cardiac replacement in the neonate.  J Heart Transplant. 1985;  4 506-509
• 2 Fricker F J, Addonizio L, Bernstein D. et al . Heart transplantation in children: indications. Report of the Ad Hoc Subcommittee of the Pediatric Committee of the American Society of Transplantation (AST).  Pediatr Transplant. 1999;  3 333-342
• 3 Human P A, Holl J, Vosloo S. et al . Extended cardiopulmonary preservation: University of Wisconsin Solution versus Bretschneider's cardioplegic solution.  Ann Thorac Surg. 1993;  55 1123-1130
• 4 Ertel W, Reichenspurner H, Lersch C, Hammer C, Plahl M, Lehmann M, Kemkes B M, Osterholzer G, Reble B, Reichart B. et al . Cytoimmunological monitoring in acute rejection and viral, bacterial or fungal infection following transplantation.  J Heart Transplant. 1985;  4 390-394
• 5 Morrow W R. The role of stress echocardiography in children.  Echocardiography. 2000;  17 507-512
• 6 Bailey L L, Assaad A N, Trimm R F. et al . Orthotopic transplantation during early infancy as therapy for incurable congenital heart disease.  Ann Surg. 1988;  208 279-786
• 7 Boucek M M, Faro A, Novick R J, Bennett L E, Keck B M, Hosenpud J D. The Registry of the International Society for Heart and Lung Transplantation: Sixth Official Pediatric Report - 2003.  J Heart Lung Transplant. 2003;  22 636-652
• 8 Groetzner J, Meiser B, Schirmer J. et al . Tacrolimus or cyclosporine for immunosuppression after cardiac transplantation: Which treatment reveals more side effects during long-term follow-up?.  TransProc. 2000;  18 234-238
• 9 Dapper F, Bauer J, Kroll J. et al . Clinical experience with heart transplantation in infants.  Eur J Cardiothorac Surg. 1998;  14 1-6 discussion 5-6
• 10 Sarris G E, Smith J A, Bernstein D. et al . Pediatric cardiac transplantation. The Stanford experience.  Circulation. 1994;  90 II51-55
• 11 Scheule A M, Zimmerman G J, Johnston J K, Razzouk A J, Gundry S R, Bailey L L. Duration of graft cold ischemia does not affect outcomes in pediatric heart transplant recipients.  Circulation. 2002;  106 I163-167
• 12 Dellgren G, Koirala B, Sakopoulus A. et al . Pediatric heart transplantation: improving results in high-risk patients.  J Thorac Cardiovasc Surg. 2001;  121 782-791
• 13 Bauer J, Thul J, Kramer U. et al . Heart transplantation in children and infants: short-term outcome and long-term follow-up.  Pediatr Transplant. 2001;  5 457-462
• 14 Luan F L, Suthanthiran M. Rapamycin is an effective inhibitor of human renal cancer metastasis.  Kidney Int. 2003;  63 917-926
• 15 Penson M G, Fricker F J, Thompson J R. et al . Safety and efficacy of pravastatin therapy for the prevention of hyperlipidemia in pediatric and adolescent cardiac transplant recipients.  J Heart Lung Transplant. 2001;  20 611-618
• 16 Wray J, Long T, Radley-Smith R, Yacoub M. Returning to school after heart or heart-lung transplantation: how well do children adjust?.  Transplantation. 2001;  15; 72 100-106
• 17 Serrano-Ikkos E, Lask B, Whitehead B, Rees P, Graham P. Heart or heart-lung transplantation: psychosocial outcome.  Pediatr Transplant. 1999;  3 301-308
• 18 Fortuna R S, Chinnock R E, Bailey L L. Heart transplantation among 233 infants during the first six months of life: the Loma Linda experience. Loma Linda Pediatric Heart TransplantGroup.  Clin Transpl. 1999;  12 263-272
• 19 Jacobs M L, Blackstone L H, Bailey L L. Intermediate survival in neonates with aortic atresia: a multi-institutional study. The Congenital Heart Surgeons Society.  J Thorac Cardiovasc Surg. 1998;  116 417-431
• 20 Daebritz S H, Nollert G D, Zurakowski D, Khalil P N, Lang P, del Nido P J, Mayer Jr J E, Jonas R A. Results of Norwood stage I operation: comparison of hypoplastic left heart syndrome with other malformations.  J Thorac Cardiovasc Surg. 2000;  119 358-367