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Dib N, Iserin L, Varnous S, Guillemain R, Hascoet S, Belli E, Cohen S. Long-term outcomes after heart transplantation in adult patients with univentricular versus biventricular congenital heart disease. Eur J Cardiothorac Surg 2024; 65:ezad410. [PMID: 38078813 DOI: 10.1093/ejcts/ezad410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 11/20/2023] [Accepted: 12/08/2023] [Indexed: 02/18/2024] Open
Abstract
OBJECTIVES Heart transplantation (HT) is the only life-extending therapy in adults with congenital heart disease (CHD) and end-stage heart failure. HT is considered at high risk in complex CHD given the anatomical complexity and past medical history. Little is known about long-term outcomes after HT in these patients. We aimed to evaluate early and long-term outcomes after HT in adult patients with univentricular versus biventricular CHD. METHODS This multicentre retrospective cohort study included all adult CHD patients who underwent HT between 1988 and 2021 in 3 tertiary centres. Factors associated with early (<30 days) and conditional long-term survival were assessed in the entire cohort. RESULTS Over a mean follow-up of 10.1 ± 7.8 years, 149 patients were included, of whom 55 (36.9%) had univentricular CHD. Sixty-four patients died during follow-up including 47 deaths before discharge from hospital. In multivariable analysis, univentricular physiology and female recipient gender were independently associated with a higher risk of early mortality (odds ratio 2.99; 95% confidence interval [1.33-6.74] and odds ratio 2.76; 95% confidence interval [1.23-6.20], respectively). For patients who survived the early period, conditional long-term survival was excellent for both groups and was not different between 2 groups (P = 0.764). CONCLUSIONS Adult CHD patients have a high incidence of overall mortality due to a high rate of early mortality. Univentricular physiology was associated with a significant increased risk of early death compared to biventricular physiology. However, late mortality was excellent and no longer different between the 2 physiologies.
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Affiliation(s)
- Nabil Dib
- Pediatric and Congenital Cardiac Surgery Department, Marie Lannelongue Hospital, Pediatric and Congenital Cardiac Surgery, M3C, Reference Center for Complex Congenital Heart Diseases, Le Plessis-Robinson, France
| | - Laurence Iserin
- Adult Congenital Heart Disease Unit, Cardiology Department, European George Pompidou Hospital, AP-HP, Paris, France
| | - Shaida Varnous
- Cardio-Thoracic Surgery Unit and Pathology Department, La Pitié-Salpétrière Hospital, AP-HP, Paris, France
| | - Romain Guillemain
- Department of Cardiovascular Surgery, European George Pompidou Hospital, AP-HP, Paris, France
| | - Sebastien Hascoet
- Pediatric and Congenital Cardiac Cardiology, Marie Lannelongue Hospital, Le Plessis-Robinson, France
- Inserm UMR-S 999, Paris-Saclay University, Le Plessis-Robinson, France
| | - Emre Belli
- Pediatric and Congenital Cardiac Surgery Department, Marie Lannelongue Hospital, Pediatric and Congenital Cardiac Surgery, M3C, Reference Center for Complex Congenital Heart Diseases, Le Plessis-Robinson, France
| | - Sarah Cohen
- Pediatric and Congenital Cardiac Cardiology, Marie Lannelongue Hospital, Le Plessis-Robinson, France
- Inserm, CESP U1018, Université Paris-Saclay, UVSQ, Le Kremlin-Bicêtre, France
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Bleiweis MS, Fricker FJ, Upchurch GR, Peek GJ, Stukov Y, Gupta D, Shih R, Pietra B, Sharaf OM, Jacobs JP. Heart Transplantation in Patients Less Than 18 Years of Age: Comparison of 2 Eras Over 36 Years and 323 Transplants at a Single Institution. J Am Coll Surg 2023; 236:898-909. [PMID: 36794835 DOI: 10.1097/xcs.0000000000000604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
BACKGROUND We reviewed our management strategy and outcome data for all 311 patients less than 18 years of age who underwent 323 heart transplants at our institution (1986 to 2022) in order to assess changes in patterns of practice and outcomes over time and to compare two consecutive eras: era 1 (154 heart transplants [1986 to 2010]) and era 2 (169 heart transplants [2011 to 2022]). STUDY DESIGN Descriptive comparisons between the two eras were performed at the level of the heart transplant for all 323 transplants. Kaplan-Meier survival analyses were performed at the level of the patient for all 311 patients, and log-rank tests were used to compare groups. RESULTS Transplants in era 2 were younger (6.6 ± 6.5 years vs 8.7 ± 6.1 years, p = 0.003). More transplants in era 2 were in infants (37.9% vs 17.5%, p < 0.0001), had congenital heart disease (53.8% vs 39.0%, p < 0.010), had high panel reactive antibody (32.1% vs 11.9%, p < 0.0001), were ABO-incompatible (11.2% vs 0.6%, p < 0.0001), had prior sternotomy (69.2% vs 39.0%, p < 0.0001), had prior Norwood (17.8% vs 0%, p < 0.0001), had prior Fontan (13.6% vs 0%, p < 0.0001), and were in patients supported with a ventricular assist device at the time of heart transplant (33.7% vs 9.1%, p < 0.0001). Survival at 1, 3, 5, and 10 years after transplant was as follows: era 1 = 82.4% (76.5 to 88.8), 76.9% (70.4 to 84.0), 70.7% (63.7 to 78.5), and 58.8% (51.3 to 67.4), respectively; era 2 = 90.3% (85.7 to 95.1), 85.4% (79.7 to 91.5), 83.0% (76.7 to 89.8), and 66.0% (49.0 to 88.8), respectively. Overall Kaplan-Meier survival in era 2 was better (log-rank p = 0.03). CONCLUSIONS Patients undergoing cardiac transplantation in the most recent era are higher risk but have better survival.
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Affiliation(s)
- Mark S Bleiweis
- From the Congenital Heart Center, Departments of Surgery and Pediatrics, University of Florida, Gainesville, FL
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Bleiweis MS, Fricker FJ, Peek GJ, Gupta D, Shih R, Pietra BB, Bobba C, Brennan Z, Mackie P, Stukov Y, Purlee M, Brown C, Kugler L, Sharaf OM, Neal D, Goldstein SS, Jacobs JP. An Analysis of 183 Heart Transplants for Pediatric or Congenital Heart Disease-Impact of High Panel Reactive Antibody. Ann Thorac Surg 2023; 115:733-741. [PMID: 36370883 DOI: 10.1016/j.athoracsur.2022.10.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 09/26/2022] [Accepted: 10/03/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND We reviewed our management strategy and outcome data for all 179 patients with pediatric and/or congenital heart disease who underwent 183 heart transplants from January 1, 2011, to December 31, 2021, and evaluated the impact of elevated panel reactive antibody (PRA). METHODS High PRA was defined as PRA >10%. Univariate associations with long-term survival were assessed with Cox proportional hazards models. Impact of high PRA on survival was estimated with multivariable models. RESULTS PRA >10% was present in 60 of 183 transplants (32.8%), who were more likely to have prior cardiac surgery, higher number of prior cardiac operations, prior sternotomy, prior heart transplant, and positive crossmatch (24 of 60 [40.0%] vs 11 of 123 [8.9%], P < .0001). Univariate associations with long-term survival include acquired heart disease vs congenital or retransplant (hazard ratio [HR], 0.18; 95% CI, 0.053-0.593; P = .005), prior cardiac surgery (HR, 5.6; 95% CI, 1.32-23.75; P = .020), number of prior cardiac operations (HR, 1.3 for each additional surgery; 95% CI, 1.12-1.50; P = .0004), single ventricle (HR, 2.4; 95% CI, 1.05-5.48; P = .038), and preoperative renal dysfunction (HR, 3.4; 95% CI, 1.43-7.49; P = .002). In multivariate analysis, high PRA does not impact survival when controlling for each of the factors shown in univariable analysis to be associated with long-term survival. The Kaplan-Meier method provided the following survival estimates at 1 year (95% CI) and 5 years (95% CI) after cardiac transplantation: All patients, 93.6% (89.9%-97.3%) and 85.8% (80.0%-92.1%); PRA <10%, 96.6% (93.4%-99.9%) and 86.7% (79.6%-94.3%); and PRA >10%, 86.7% (78.0%-96.4%) and 83.8% (74.0%-95.0%). Despite high PRA being associated with higher mortality at 1 year (14.9% vs 3.8%, P = .035), no significant difference exists in Kaplan-Meier overall survival at 5 years posttransplant in patients with and without high PRA (log-rank P = .4). CONCLUSIONS In our cohort, 5-year survival in patients with high PRA (PRA >10%) is similar to that in patients without high PRA (PRA <10%), despite the presence of more risk factors in those with high PRA. Individualized immunomodulatory strategies can potentially mitigate the risk of high PRA.
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Affiliation(s)
- Mark S Bleiweis
- Congenital Heart Center, University of Florida, Gainesville, Florida.
| | | | - Giles J Peek
- Congenital Heart Center, University of Florida, Gainesville, Florida
| | - Dipankar Gupta
- Congenital Heart Center, University of Florida, Gainesville, Florida
| | - Renata Shih
- Congenital Heart Center, University of Florida, Gainesville, Florida
| | | | - Chris Bobba
- Congenital Heart Center, University of Florida, Gainesville, Florida
| | - Zachary Brennan
- Congenital Heart Center, University of Florida, Gainesville, Florida
| | - Phil Mackie
- Congenital Heart Center, University of Florida, Gainesville, Florida
| | - Yuriy Stukov
- Congenital Heart Center, University of Florida, Gainesville, Florida
| | - Matthew Purlee
- Congenital Heart Center, University of Florida, Gainesville, Florida
| | - Colton Brown
- Congenital Heart Center, University of Florida, Gainesville, Florida
| | - Liam Kugler
- Congenital Heart Center, University of Florida, Gainesville, Florida
| | - Omar M Sharaf
- Congenital Heart Center, University of Florida, Gainesville, Florida
| | - Dan Neal
- Congenital Heart Center, University of Florida, Gainesville, Florida
| | - Steven S Goldstein
- Department of Pathology & Immunology, University of Florida, Gainesville, Florida
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Greenberg JW, Guzman-Gomez A, Kulshrestha K, Dani A, Lehenbauer DG, Chin C, Zafar F, Morales DLS. Contemporary Outcomes of Heart Transplantation in Children with Heterotaxy Syndrome: Sub-Optimal Pre-Transplant Optimization Translates into Early Post-Transplant Mortality. Pediatr Cardiol 2023:10.1007/s00246-023-03122-z. [PMID: 36811659 DOI: 10.1007/s00246-023-03122-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/02/2023] [Indexed: 02/24/2023]
Abstract
Patients with heterotaxy syndrome and congenital heart disease (CHD) experience inferior cardiac surgical outcomes. Heart transplantation outcomes are understudied, however, particularly compared to non-CHD patients. Data from UNOS and PHIS were used to identify 4803 children (< 18 years) undergoing first-time heart transplant between 2003 and 2022 with diagnoses of heterotaxy (n = 278), other-CHD (n = 2236), and non-CHD cardiomyopathy (n = 2289). Heterotaxy patients were older (median 5 yr) and heavier (median 17 kg) at transplant than other-CHD (median 2 yr and 12 kg), and younger and lighter than cardiomyopathy (median 7 yr and 24 kg) (all p < 0.001). UNOS status 1A/1 at listing was not different between groups (65-67%; p = 0.683). At transplant, heterotaxy and other-CHD patients had similar rates of renal dysfunction (12 and 17%), inotropes (10% and 11%), and ventilator-dependence (19 and 18%). Compared to cardiomyopathy, heterotaxy patients had comparable renal dysfunction (9%, p = 0.058) and inotropes (46%, p = 0.097) but more hepatic dysfunction (17%, p < 0.001) and ventilator-dependence (12%, p = 0.003). Rates of ventricular assist device (VAD) were: heterotaxy-10%, other-CHD-11% (p = 0.839 vs. heterotaxy), cardiomyopathy-37% (p < 0.001 vs. heterotaxy). The 1-year incidence of acute rejection post-transplant was comparable between heterotaxy and others (p > 0.05). While overall post-transplant survival was significantly worse for heterotaxy than others (p < 0.05 vs. both), conditional 1-year survival was comparable (p > 0.3 vs. both). Children with heterotaxy syndrome experience inferior post-heart transplant survival, although early mortality appears to influence this trend, with 1-year survivors having equivalent outcomes. Given similar pre-transplant clinical status to others, heterotaxy patients are potentially under risk-stratified. Increased VAD utilization and pre-transplant end-organ function optimization may portend improved outcomes.
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Affiliation(s)
- Jason W Greenberg
- Cincinnati Children's Hospital Medical Center, The Heart Institute, University of Cincinnati School of Medicine, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.
| | - Amalia Guzman-Gomez
- Cincinnati Children's Hospital Medical Center, The Heart Institute, University of Cincinnati School of Medicine, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - Kevin Kulshrestha
- Cincinnati Children's Hospital Medical Center, The Heart Institute, University of Cincinnati School of Medicine, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - Alia Dani
- Cincinnati Children's Hospital Medical Center, The Heart Institute, University of Cincinnati School of Medicine, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - David G Lehenbauer
- Cincinnati Children's Hospital Medical Center, The Heart Institute, University of Cincinnati School of Medicine, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - Clifford Chin
- Cincinnati Children's Hospital Medical Center, The Heart Institute, University of Cincinnati School of Medicine, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - Farhan Zafar
- Cincinnati Children's Hospital Medical Center, The Heart Institute, University of Cincinnati School of Medicine, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - David L S Morales
- Cincinnati Children's Hospital Medical Center, The Heart Institute, University of Cincinnati School of Medicine, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
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Greenberg JW, Raees MA, Dani A, Heydarian HC, Chin C, Zafar F, Lehenbauer DG, Morales DLS. Palliated Hypoplastic Left Heart Syndrome Patients Experience Superior Waitlist and Comparable Post-Heart Transplant Survival to Non-Single Ventricle Congenital Heart Disease Patients. Semin Thorac Cardiovasc Surg 2022; 36:230-241. [PMID: 36455711 PMCID: PMC10225473 DOI: 10.1053/j.semtcvs.2022.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 08/31/2022] [Indexed: 11/30/2022]
Abstract
Congenital heart disease (CHD) is a well-established risk factor for inferior waitlist and post-heart transplant survival in children. Differences in outcomes between CHD subgroups are understudied. The present study compared outcomes for palliated hypoplastic left heart syndrome (HLHS) patients to other non-single ventricle CHD (non-SVCHD) and non-CHD patients. United Network for Organ Sharing was used to identify children (age < 18) listed for heart transplant in the United States between 2016 and 2021. CHD sub-diagnoses were only available for United Network for Organ Sharing status 1a after 2015, thereby defining the cohort. Waitlist outcomes were studied using competing-risk time-to-event analysis for transplantation, mortality/decompensation, and alive-on-waitlist. Multivariable Cox proportional hazards regression analyses were used to identify factors associated with inferior post-transplant survival. Patients included: palliated-HLHS (n = 477), non-SVCHD (n = 686), and non-CHD (n = 1261). At listing, Palliated-HLHS patients were older than non-SVCHD (median 2-year [IQR 0-8] vs median 0-year [0-3], respectively) and younger than non-CHD (median 7-year [0-14]) (P < 0.001 vs both), and were more likely to be white (P < 0.01 vs both). Upon time-to-event analysis, rates of waitlist mortality/decompensation rates were greater among non-SVCHD than palliated-HLHS. Post-transplant survival was comparable between palliated-HLHS and non-SVCHD (P = 0.920) but worse compared to non-CHD (P < 0.001). Both palliated-HLHS (HR 2.40 [95% CI 1.68-3.42]) and non-SVSCHD (2.04 [1.39-2.99]) were independently associated with post-transplant mortality. Palliated-HLHS patients with heart failure experience significantly worse post-transplant outcomes than non-CHD but, compared to other CHD patients, experience superior waitlist and comparable post-transplant survival. While a high-risk cohort, HLHS patients can achieve gratifying waitlist and post-transplant survival.
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Affiliation(s)
- Jason W Greenberg
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio.
| | - Muhammad Aanish Raees
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Alia Dani
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Haleh C Heydarian
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Clifford Chin
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Farhan Zafar
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David G Lehenbauer
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David L S Morales
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Jacobs JP, Quintessenza JA, van Gelder HM, Staples ED, Martin TD, Arnaoutakis GJ, Beaver TM, Peek GJ, Nixon CS, Bleiweis MS, Mavroudis C. George Daicoff: A Pioneering Surgeon and Humanitarian of The Southern Thoracic Surgical Association. Ann Thorac Surg 2022; 113:1743-1749. [DOI: 10.1016/j.athoracsur.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 12/10/2021] [Accepted: 12/10/2022] [Indexed: 11/01/2022]
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Khan A, Pahl E, Koehl DA, Cantor RS, Kirklin JK, Rusconi P, Barnes AP, Azeka E, Everitt MD. Improved heart transplant survival for children with congenital heart disease and heterotaxy syndrome in the current era: An analysis from the pediatric heart transplant society. J Heart Lung Transplant 2021; 40:1153-1163. [PMID: 34366230 DOI: 10.1016/j.healun.2021.07.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 06/01/2021] [Accepted: 07/08/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Challenges exist with heterotaxy due to the complexity of heart disease, abnormal venous connections, and infection risks. This study aims to understand heart transplant outcomes for children with heterotaxy. METHODS All children with congenital heart disease listed for transplant from 1993 to 2018 were included. Those with and without heterotaxy were compared. Waitlist outcomes and survival post-listing and transplant were analyzed. Post-transplant risk factors were identified using multiphase parametric hazard modeling. RESULTS There were 4814 children listed, of whom 196 (4%) had heterotaxy. Heterotaxy candidates were older (5.8 ± 5.7 vs 4.2 ± 5.5 years, p < 0.01), listed at a lower urgency status (29.8% vs 18.4%, p < 0.01), more commonly single ventricle physiology (71.3% vs 59.2%, p < 0.01), and less often supported by mechanical ventilation (22% vs 29.1%, p < 0.05) or extracorporeal membrane oxygenation (3.6% vs 7.5%, p < 0.05). There were no differences in waitlist outcomes of transplant, death, or removal. Overall, post-transplant survival was worse for children with heterotaxy: one-year survival 77.2% vs 85.1%, with and without heterotaxy, respectively. Heterotaxy was an independent predictor for early mortality in the earliest era (1993-2004), HR 2.09, CI 1.16-3.75, p = 0.014. When stratified by era, survival improved with time. Heterotaxy patients had a lower freedom from infection and from severe rejection, but no difference in vasculopathy or malignancy. CONCLUSIONS Mortality risk associated with heterotaxy is mitigated in the recent transplant era. Early referral may improve waitlist outcomes for heterotaxy patients who otherwise have a lower status at listing. Lower freedom from both infection and severe rejection after transplant in heterotaxy highlights the challenges of balancing immune suppression.
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Affiliation(s)
- Asma Khan
- Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern Feinberg School of Medicine, Chicago
| | - Elfriede Pahl
- Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern Feinberg School of Medicine, Chicago
| | - Devin A Koehl
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ryan S Cantor
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - James K Kirklin
- Kirklin Institute for Research in Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama
| | - Paolo Rusconi
- Department of Pediatrics, University of Miami, Miller School of Medicine, Jackson Memorial Hospital, Miami, Florida
| | - Aliessa P Barnes
- Department of Pediatrics, Division of Pediatric Cardiology, University of Missouri-Kansas City, Kansas City, Missouri
| | - Estela Azeka
- Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | - Melanie D Everitt
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, Colorado.
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Riggs KW, Broderick JT, Price N, Chin C, Zafar F, Morales DLS. Transplantation for Congenital Heart Disease: Focus on the Impact of Functionally Univentricular Versus Biventricular Circulation. World J Pediatr Congenit Heart Surg 2021; 12:352-359. [PMID: 33942695 DOI: 10.1177/2150135121990650] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Varying single center data exist regarding the posttransplant outcomes of patients with single ventricle circulation, particularly following the Fontan operation. We sought to better elucidate these results in patients with congenital heart disease (CHD) through combining two national databases. METHODS The United Network for Organ Sharing (UNOS) transplantation database was merged with the Pediatric Health Information System (PHIS), an administrative database with 71% of UNOS patients matched. Patients undergoing transplantation at a PHIS hospital from 2006 to 2017 were categorized as single ventricle or biventricular strategy based on their diagnoses and procedures in 90% of patients. When known, single ventricle patients were further analyzed by their palliative stage post-Glenn or post-Fontan (known in 31%). RESULTS A total of 1,517 CHD transplantations were identified, 67% with single ventricle strategy (1,016). Single ventricle, biventricular, and indeterminate patients had similar survival (log-rank P > .1). Risk factors for mortality in patients with CHD were extracorporeal membrane oxygenation (ECMO) support at transplant (hazard: 2.27), ABO blood type incompatibility (hazard: 1.61), African American recipient (hazard 1.42), and liver dysfunction (hazard 1.29). A total of 130 confirmed Fontan and 185 confirmed bidirectional Glenn patients underwent transplantation, each with survival equivalent to biventricular patients (log-rank P > .500). For Fontan patients, renal dysfunction (hazard: 5.40) and transplant <1 year after Fontan (hazard 2.82) were found to be associated with mortality. CONCLUSIONS Single ventricle patients, as a group, experience similar outcomes as biventricular patients with CHD undergoing transplantation, and this extends to Fontan patients. Risk factors for mortality correlate with end-organ dysfunction as well as race and ABO blood type incompatibility in the CHD population.
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Affiliation(s)
- Kyle W Riggs
- Heart Institute, 2518Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - John T Broderick
- Heart Institute, 2518Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Nina Price
- Heart Institute, 2518Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Clifford Chin
- Heart Institute, 2518Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Farhan Zafar
- Heart Institute, 2518Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - David L S Morales
- Heart Institute, 2518Cincinnati Children's Hospital, Cincinnati, OH, USA
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The reality of limping to pediatric heart transplantation. J Thorac Cardiovasc Surg 2019; 159:2418-2425.e1. [PMID: 31839235 DOI: 10.1016/j.jtcvs.2019.10.077] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 09/11/2019] [Accepted: 10/01/2019] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Improvements in surgical technique, critical care, and early repair for congenital heart disease (CHD) have led to improved outcomes with heart transplantation, often used as a salvage procedure after failed palliation, especially in infants. These patients, however, often have several risk factors for poor posttransplant survival. We aimed to identify the reality of survival after heart transplantation in patients "limping to transplant" with common risk factors. METHODS All heart transplant recipients younger than 18 years were identified from the UNOS data set from 2000 to 2017. Modifiable risk factors (MRFs) of mechanical ventilation, renal dysfunction, and liver dysfunction at transplant and nonmodifiable risk factors of infancy at listing or CHD were examined. One-year posttransplant survival was analyzed with logistic regression. RESULTS Of 4101 transplants, 1459 patients (36%) had 1 or more MRFs. There was a decrease in 1-year survival with additional MRFs up to a 9.1-times increased risk of death in an infant with CHD. A noninfant without CHD and no MRFs had a 95% 1-year survival, in contrast to an intubated patient with CHD without other end-organ dysfunction, who had 1-year survival of 76%, which decreased to 58% if they were an infant and also had renal dysfunction. CONCLUSIONS Patients "limping to transplant" with multiple risk factors demonstrates decreasing early survival relative to those without other end-organ dysfunction. It is imperative that we have transparent discussions about expected outcomes with these families and identify ways to optimize patients' conditions through other supportive avenues to improve posttransplant outcomes.
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10
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Duong SQ, Godown J, Soslow JH, Thurm C, Hall M, Sainathan S, Morell VO, Dodd DA, Feingold B. Increased mortality, morbidities, and costs after heart transplantation in heterotaxy syndrome and other complex situs arrangements. J Thorac Cardiovasc Surg 2019; 157:730-740.e11. [PMID: 30669235 PMCID: PMC6865268 DOI: 10.1016/j.jtcvs.2018.11.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 10/22/2018] [Accepted: 11/04/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Identify pediatric heart transplant (HT) recipients with heterotaxy and other complex arrangements of cardiac situs (heterotaxy/situs anomaly) and compare mortality, morbidities, length of stay (LOS), and costs to recipients with congenital heart disease without heterotaxy/situs anomaly. METHODS Using linked registry data (2001-2016), we identified 186 HT recipients with heterotaxy/situs anomaly and 1254 with congenital heart disease without heterotaxy/situs anomaly. We compared post-HT outcomes in univariable and multivariable time-to-event analyses. LOS and cost from HT to discharge were compared using Wilcoxon rank-sum tests. Sensitivity analyses were performed using stricter heterotaxy/situs anomaly group inclusion criteria and through propensity matching. RESULTS HT recipients with heterotaxy/situs anomaly were older (median age, 5.1 vs 1.6 years; P < .001) and more often black, Asian, Hispanic, or "other" nonwhite (54% vs 32%; P < .001). Heterotaxy/situs anomaly was independently associated with increased mortality (hazard ratio, 1.58; 95% confidence interval, 1.19-2.09; P = .002), even among 6-month survivors (hazard ratio, 1.86; 95% confidence interval, 1.09-3.16; P = .021). Heterotaxy/situs anomaly recipients more commonly required dialysis (odds ratio, 2.58; 95% confidence interval, 1.51-4.42; P = .001) and cardiac reoperation (odds ratio, 1.91; 95% confidence interval, 1.17-3.11; P = .010) before discharge. They had longer ischemic times (19.2 additional minutes [range, 10.9-27.5 minutes]; P < .001), post-HT intensive care unit LOS (16 vs 13 days; P = .012), and hospital LOS (26 vs 23 days; P = .005). Post-HT hospitalization costs were also greater ($447,604 vs $379,357; P = .001). CONCLUSIONS Heterotaxy and other complex arrangements of cardiac situs are associated with increased mortality, postoperative complications, LOS, and costs after HT. Although increased surgical complexity can account for many of these differences, inferior late survival is not well explained and deserves further study.
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Affiliation(s)
- Son Q Duong
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Justin Godown
- Division of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tenn
| | - Jonathan H Soslow
- Division of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tenn
| | - Cary Thurm
- Children's Hospital Association, Lenexa, Kan
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kan
| | - Sandeep Sainathan
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Victor O Morell
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Debra A Dodd
- Division of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tenn
| | - Brian Feingold
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pa; Department of Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pa.
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11
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Shah S, Asante-Korang A, Ghazarian SR, Stapleton G, Herbert C, Decker J, Almodovar MC, Karl TR, Do NL, Quintessenza JA, Mavroudis C, Vricella LA, van Gelder HM, Kartha V, Alexander P, Carapellucci J, Krasnopero D, Hanson J, Amankwah E, Roth J, Jacobs JP. Risk Factors for Survival After Heart Transplantation in Children and Young Adults: A 22-Year Study of 179 Transplants. World J Pediatr Congenit Heart Surg 2018; 9:557-564. [PMID: 30157732 DOI: 10.1177/2150135118782190] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND This article reviews all patients who underwent heart transplantation (HTx) within a single institution (172 patients underwent 179 HTx [167 first-time HTxs, 10 second HTxs, 2 third HTxs]) to describe diagnostic characteristics, management protocols, and risk factors for mortality. METHODS Descriptive analysis was performed for the entire cohort using mean, standard deviation, median, interquartile range, and overall range, as appropriate. Univariable and multivariable Cox proportional hazards models were performed to identify prognostic factors for outcomes over time. The primary outcome of interest was mortality, which was modeled by Kaplan-Meier analysis. RESULTS Median age at HTx was 263 days (range, 5 days to 24 years; mean = 4.63 ± 5.95 years; 18 neonates, 79 infants). Median weight at HTx was 7.5 kg (range, 2.2-113 kg; mean = 19.36 ± 23.54). Diagnostic categories were cardiomyopathy (n = 62), primary transplantation for hypoplastic left heart syndrome (HLHS) or HLHS-related malformation (n = 33), transplantation after cardiac surgery for HLHS or HLHS-related malformation (n = 17), non-HLHS congenital heart disease (n = 55), and retransplant (n = 12). Operative mortality was 10.1% (18 patients). Cumulative total follow-up is 1,355 years. Late mortality was 18.4% (33 patients). Overall Kaplan-Meier five-year survival was 76.2%. One hundred twenty-one patients are alive with a mean follow-up of 7.61 ± 6.46 years. No survival differences were seen among the five diagnostic subgroups ( P = .064) or between immunosensitized patients (n = 31) and nonimmunosensitized patients (n = 141; P = .422). CONCLUSIONS Excellent results are expected for children undergoing HTx with comparable results among diagnostic groups. Pretransplant mechanical circulatory support and posttransplant mechanical circulatory support are risk factors for decreased survival. Survival after transplantation for HLHS or HLHS-related malformation is better with primary HTx in comparison to HTx after prior cardiac surgery.
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Affiliation(s)
- Shawn Shah
- 1 Divisions of Cardiovascular Surgery, Cardiology, Cardiac Critical Care, Cardiac Anesthesia, Johns Hopkins All Children's Hospital, Johns Hopkins All Children's Hospital, Saint Petersburg, Tampa, and Orlando, FL, USA
| | - Alfred Asante-Korang
- 1 Divisions of Cardiovascular Surgery, Cardiology, Cardiac Critical Care, Cardiac Anesthesia, Johns Hopkins All Children's Hospital, Johns Hopkins All Children's Hospital, Saint Petersburg, Tampa, and Orlando, FL, USA
| | - Sharon R Ghazarian
- 2 Health Informatics, Johns Hopkins All Children's Hospital, Saint Petersburg, FL, USA
| | - Gary Stapleton
- 1 Divisions of Cardiovascular Surgery, Cardiology, Cardiac Critical Care, Cardiac Anesthesia, Johns Hopkins All Children's Hospital, Johns Hopkins All Children's Hospital, Saint Petersburg, Tampa, and Orlando, FL, USA
| | - Carrie Herbert
- 1 Divisions of Cardiovascular Surgery, Cardiology, Cardiac Critical Care, Cardiac Anesthesia, Johns Hopkins All Children's Hospital, Johns Hopkins All Children's Hospital, Saint Petersburg, Tampa, and Orlando, FL, USA
| | - Jamie Decker
- 1 Divisions of Cardiovascular Surgery, Cardiology, Cardiac Critical Care, Cardiac Anesthesia, Johns Hopkins All Children's Hospital, Johns Hopkins All Children's Hospital, Saint Petersburg, Tampa, and Orlando, FL, USA
| | - Melvin C Almodovar
- 1 Divisions of Cardiovascular Surgery, Cardiology, Cardiac Critical Care, Cardiac Anesthesia, Johns Hopkins All Children's Hospital, Johns Hopkins All Children's Hospital, Saint Petersburg, Tampa, and Orlando, FL, USA
| | - Tom R Karl
- 1 Divisions of Cardiovascular Surgery, Cardiology, Cardiac Critical Care, Cardiac Anesthesia, Johns Hopkins All Children's Hospital, Johns Hopkins All Children's Hospital, Saint Petersburg, Tampa, and Orlando, FL, USA.,3 Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nhue L Do
- 1 Divisions of Cardiovascular Surgery, Cardiology, Cardiac Critical Care, Cardiac Anesthesia, Johns Hopkins All Children's Hospital, Johns Hopkins All Children's Hospital, Saint Petersburg, Tampa, and Orlando, FL, USA.,3 Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Constantine Mavroudis
- 1 Divisions of Cardiovascular Surgery, Cardiology, Cardiac Critical Care, Cardiac Anesthesia, Johns Hopkins All Children's Hospital, Johns Hopkins All Children's Hospital, Saint Petersburg, Tampa, and Orlando, FL, USA.,3 Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Luca A Vricella
- 1 Divisions of Cardiovascular Surgery, Cardiology, Cardiac Critical Care, Cardiac Anesthesia, Johns Hopkins All Children's Hospital, Johns Hopkins All Children's Hospital, Saint Petersburg, Tampa, and Orlando, FL, USA.,3 Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Vyas Kartha
- 1 Divisions of Cardiovascular Surgery, Cardiology, Cardiac Critical Care, Cardiac Anesthesia, Johns Hopkins All Children's Hospital, Johns Hopkins All Children's Hospital, Saint Petersburg, Tampa, and Orlando, FL, USA
| | - Plato Alexander
- 1 Divisions of Cardiovascular Surgery, Cardiology, Cardiac Critical Care, Cardiac Anesthesia, Johns Hopkins All Children's Hospital, Johns Hopkins All Children's Hospital, Saint Petersburg, Tampa, and Orlando, FL, USA
| | - Jennifer Carapellucci
- 1 Divisions of Cardiovascular Surgery, Cardiology, Cardiac Critical Care, Cardiac Anesthesia, Johns Hopkins All Children's Hospital, Johns Hopkins All Children's Hospital, Saint Petersburg, Tampa, and Orlando, FL, USA
| | - Diane Krasnopero
- 1 Divisions of Cardiovascular Surgery, Cardiology, Cardiac Critical Care, Cardiac Anesthesia, Johns Hopkins All Children's Hospital, Johns Hopkins All Children's Hospital, Saint Petersburg, Tampa, and Orlando, FL, USA
| | - Jade Hanson
- 1 Divisions of Cardiovascular Surgery, Cardiology, Cardiac Critical Care, Cardiac Anesthesia, Johns Hopkins All Children's Hospital, Johns Hopkins All Children's Hospital, Saint Petersburg, Tampa, and Orlando, FL, USA
| | - Ernest Amankwah
- 2 Health Informatics, Johns Hopkins All Children's Hospital, Saint Petersburg, FL, USA
| | - Joeli Roth
- 1 Divisions of Cardiovascular Surgery, Cardiology, Cardiac Critical Care, Cardiac Anesthesia, Johns Hopkins All Children's Hospital, Johns Hopkins All Children's Hospital, Saint Petersburg, Tampa, and Orlando, FL, USA
| | - Jeffrey P Jacobs
- 1 Divisions of Cardiovascular Surgery, Cardiology, Cardiac Critical Care, Cardiac Anesthesia, Johns Hopkins All Children's Hospital, Johns Hopkins All Children's Hospital, Saint Petersburg, Tampa, and Orlando, FL, USA.,3 Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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12
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Park CS, Villa CR, Lorts A, Chin C, Tweddell JS, Zafar F, Morales DLS. Is there an optimal organ acceptance rate for pediatric heart transplantation: "A sweet spot"? Pediatr Transplant 2018; 22:e13149. [PMID: 29380475 DOI: 10.1111/petr.13149] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/30/2017] [Indexed: 11/30/2022]
Abstract
Despite a limited supply of donors, potential donor hearts are often declined for subjective concerns regarding organ quality. This analysis will investigate the relationship between donor heart AR and patient outcome at pediatric transplant centers. The UNOS database was used to identify all match runs for pediatric candidates (age < 18 years) from 2008 through March 2015 in which a heart offer was ultimately placed. Centers which received ≥10 offers/y were included (10 634 offers, 38 centers). Transplant centers were stratified based on their AR: low (<20%, n = 13), medium (20%-40%, n = 16), or high (>40%, n = 9). Low AR centers experienced worse negative WL outcome compared with medium (P = .022) and high (P = .004) AR centers. Low AR centers had similar post-transplant graft survival to medium (P = .311) or high (P = .393) AR centers; however, medium AR centers had better post-transplant graft survival than high AR centers (P = .037). E-F survival from listing regardless of transplant was worse for low AR centers compared with medium (P < .001) or high (P = .001) AR centers. Low AR centers experience worse WL outcomes without improvement in post-transplant outcomes. High AR centers experience higher post-transplant graft failure than medium AR centers. AR of 20%-40% appears to have optimal WL and post-transplant outcomes.
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Affiliation(s)
- Chun Soo Park
- Division of Pediatric Cardiac Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chet R Villa
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Angela Lorts
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Clifford Chin
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - James S Tweddell
- Department of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Farhan Zafar
- Department of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David L S Morales
- Department of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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13
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Khan AM, Green RS, Lytrivi ID, Sahulee R. Donor predictors of allograft utilization for pediatric heart transplantation. Transpl Int 2016; 29:1269-1275. [DOI: 10.1111/tri.12835] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 05/05/2016] [Accepted: 08/06/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Asma M. Khan
- Division of Cardiology; Department of Pediatrics; Icahn School of Medicine at Mount Sinai; New York NY USA
| | - Robert S. Green
- Division of Newborn Medicine; Department of Pediatrics; Icahn School of Medicine at Mount Sinai; New York NY USA
| | - Irene D. Lytrivi
- Division of Cardiology; Department of Pediatrics; Icahn School of Medicine at Mount Sinai; New York NY USA
| | - Raj Sahulee
- Division of Cardiology; Department of Pediatrics; Icahn School of Medicine at Mount Sinai; New York NY USA
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14
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Wehman B, Stafford KA, Bittle GJ, Kon ZN, Evans CF, Rajagopal K, Pietris N, Kaushal S, Griffith BP. Modern Outcomes of Mechanical Circulatory Support as a Bridge to Pediatric Heart Transplantation. Ann Thorac Surg 2016; 101:2321-7. [PMID: 26912304 DOI: 10.1016/j.athoracsur.2015.12.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 10/17/2015] [Accepted: 12/07/2015] [Indexed: 01/20/2023]
Abstract
BACKGROUND Pediatric patients awaiting orthotopic heart transplantation frequently require bridge to transplantation (BTT) with mechanical circulatory support. Posttransplant survival outcomes and predictors of mortality have not been thoroughly described in the modern era using a large-scale analysis. METHODS The United Network for Organ Sharing database was reviewed to identify pediatric heart transplant recipients from 2005 through 2012. Patients were stratified into three groups: extracorporeal membrane oxygenation (ECMO), ventricular assist device (VAD), and direct transplantation (DTXP). The primary outcome was posttransplant survival. RESULTS Two thousand seven hundred seventy-seven pediatric patients underwent orthotopic heart transplantation. There were 617 patients who required BTT with mechanical circulatory support (22.2%), of whom there were 428 VAD BTT (69.4%) and 189 ECMO BTT (30.6%). An increase in VAD use was observed during the study period (p < 0.0001). Compared with DTXP, patients in the ECMO BTT group had a lower median age (<1 versus 5 years; p < 0.0001) and were significantly smaller (8 versus 14 kg; p < 0.001), whereas patients in the VAD BTT group were older (8 versus 5 years; p = 0.0002) and larger (24 versus 14 kg; p < 0.001). Actuarial survival was greater in the DTXP group compared with ECMO BTT, but similar to VAD BTT at 30 days and 1, 3, and 5 years. However, this survival difference was lost after censoring the first 4 months after transplant. In multivariable analysis, when restricted to the first 4 months of survival, independent predictors for mortality were ECMO BTT, age, diagnosis, and functional status, whereas VAD BTT was not. CONCLUSIONS Pediatric patients with DTXP or VAD BTT have equivalent posttransplant survival. However, those requiring ECMO BTT have inferior early posttransplant survival compared with those receiving DTXP.
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Affiliation(s)
- Brody Wehman
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kristen A Stafford
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Gregory J Bittle
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Zachary N Kon
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Charles F Evans
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Keshava Rajagopal
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Nicholas Pietris
- Division of Pediatric Cardiology, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Sunjay Kaushal
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Bartley P Griffith
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland.
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15
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Alsoufi B, Mahle WT, Manlhiot C, Deshpande S, Kogon B, McCrindle BW, Kanter K. Outcomes of heart transplantation in children with hypoplastic left heart syndrome previously palliated with the Norwood procedure. J Thorac Cardiovasc Surg 2016; 151:167-74, 175.e1-2. [DOI: 10.1016/j.jtcvs.2015.09.081] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 09/01/2015] [Accepted: 09/12/2015] [Indexed: 11/16/2022]
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16
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Abstract
CHD is frequently associated with a genetic syndrome. These syndromes often present specific cardiovascular and non-cardiovascular co-morbidities that confer significant peri-operative risks affecting multiple organ systems. Although surgical outcomes have improved over time, these co-morbidities continue to contribute substantially to poor peri-operative mortality and morbidity outcomes. Peri-operative morbidity may have long-standing ramifications on neurodevelopment and overall health. Recognising the cardiovascular and non-cardiovascular risks associated with specific syndromic diagnoses will facilitate expectant management, early detection of clinical problems, and improved outcomes--for example, the development of syndrome-based protocols for peri-operative evaluation and prophylactic actions may improve outcomes for the more frequently encountered syndromes such as 22q11 deletion syndrome.
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17
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Shi WY, Saxena P, Yong MS, Marasco SF, McGiffin DC, Shipp A, Weintraub RG, d'Udekem Y, Brizard CP, Konstantinov IE. Increasing Complexity of Heart Transplantation in Patients With Congenital Heart Disease. Semin Thorac Cardiovasc Surg 2016; 28:487-497. [DOI: 10.1053/j.semtcvs.2015.09.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2015] [Indexed: 11/11/2022]
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18
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Outcomes and risk factors for heart transplantation in children with congenital heart disease. J Thorac Cardiovasc Surg 2015; 150:1455-62.e3. [DOI: 10.1016/j.jtcvs.2015.06.029] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Revised: 06/04/2015] [Accepted: 06/07/2015] [Indexed: 11/19/2022]
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19
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Introduction to the 2015 Supplement to Cardiology in the Young: Proceedings of the 2015 International Pediatric Heart Failure Summit of Johns Hopkins All Children's Heart Institute. Cardiol Young 2015; 25 Suppl 2:1-7. [PMID: 26377706 DOI: 10.1017/s1047951115001742] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
In the United States of America alone, ~14,000 children are hospitalised annually with acute heart failure. The science and art of caring for these patients continues to evolve. The International Pediatric Heart Failure Summit of Johns Hopkins All Children's Heart Institute was held on 4 and 5 February, 2015. The 2015 International Pediatric Heart Failure Summit of Johns Hopkins All Children's Heart Institute was funded through the Andrews/Daicoff Cardiovascular Program Endowment, a philanthropic collaboration between All Children's Hospital and the Morsani College of Medicine at the University of South Florida (USF). Sponsored by All Children's Hospital Andrews/Daicoff Cardiovascular Program, the Johns Hopkins All Children's Heart Institute International Pediatric Heart Failure Summit assembled leaders in clinical and scientific disciplines related to paediatric heart failure and created a multi-disciplinary "think-tank". Information about George R. Daicoff, MD, and Ed and Sarainne Andrews is provided in this introductory manuscript to the 2015 Supplement to Cardiology in the Young entitled: "Proceedings of the 2015 International Pediatric Heart Failure Summit of Johns Hopkins All Children's Heart Institute". Dr Daicoff founded the All Children's Hospital Pediatric Heart Surgery programme and directed this programme for over two decades. Sarainne Andrews made her generous bequest to All Children's Hospital in honour of her husband Ed and his friendship with Dr Daicoff in order to support cardiovascular surgery research efforts.
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20
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Summary of the 2015 International Paediatric Heart Failure Summit of Johns Hopkins All Children's Heart Institute. Cardiol Young 2015; 25 Suppl 2:8-30. [PMID: 26377707 DOI: 10.1017/s1047951115001353] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
In the United States alone, ∼14,000 children are hospitalised annually with acute heart failure. The science and art of caring for these patients continues to evolve. The International Pediatric Heart Failure Summit of Johns Hopkins All Children's Heart Institute was held on February 4 and 5, 2015. The 2015 International Pediatric Heart Failure Summit of Johns Hopkins All Children's Heart Institute was funded through the Andrews/Daicoff Cardiovascular Program Endowment, a philanthropic collaboration between All Children's Hospital and the Morsani College of Medicine at the University of South Florida (USF). Sponsored by All Children's Hospital Andrews/Daicoff Cardiovascular Program, the International Pediatric Heart Failure Summit assembled leaders in clinical and scientific disciplines related to paediatric heart failure and created a multi-disciplinary "think-tank". The purpose of this manuscript is to summarise the lessons from the 2015 International Pediatric Heart Failure Summit of Johns Hopkins All Children's Heart Institute, to describe the "state of the art" of the treatment of paediatric cardiac failure, and to discuss future directions for research in the domain of paediatric cardiac failure.
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21
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Reinhartz O, Maeda K, Reitz BA, Bernstein D, Luikart H, Rosenthal DN, Hollander SA. Changes in Risk Profile Over Time in the Population of a Pediatric Heart Transplant Program. Ann Thorac Surg 2015; 100:989-94; discussion 995. [PMID: 26228604 DOI: 10.1016/j.athoracsur.2015.05.111] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 04/29/2015] [Accepted: 05/04/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Single-center data on pediatric heart transplantation spanning long time frames is sparse. We attempted to analyze how risk profile and pediatric heart transplant survival outcomes at a large center changed over time. METHODS We divided 320 pediatric heart transplants done at Stanford University between 1974 and 2014 into three groups by era: the first 20 years (95 transplants), the subsequent 10 years (87 transplants), and the most recent 10 years (138 transplants). Differences in age at transplant, indication, mechanical support, and survival were analyzed. RESULTS Follow-up was 100% complete. Average age at time of transplantation was 10.4 years, 11.9 years, and 5.6 years in eras 1, 2, and 3, respectively. The percentage of infants who received transplants by era was 21%, 7%, and 18%, respectively. The indication of end-stage congenital heart disease vs cardiomyopathy was 24%, 22%, and 49%, respectively. Only 1 patient (1%) was on mechanical support at transplant in era 1 compared with 15% in era 2 and 30% in era 3. Overall survival was 72% at 5 years and 57% at 10 years. Long-term survival increased significantly with each subsequent era. Patients with cardiomyopathy generally had a survival advantage over those with congenital heart disease. CONCLUSIONS The risk profile of pediatric transplant patients in our institution has increased over time. In the last 10 years, median age has decreased and ventricular assist device support has increased dramatically. Transplantation for end-stage congenital heart disease is increasingly common. Despite this, long-term survival has significantly and consistently improved.
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Affiliation(s)
- Olaf Reinhartz
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California.
| | - Katsuhide Maeda
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
| | - Bruce A Reitz
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
| | - Daniel Bernstein
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Stanford, California
| | - Helen Luikart
- Department of Cardiology, Stanford University, Stanford, California
| | - Daniel N Rosenthal
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Stanford, California
| | - Seth A Hollander
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Stanford, California
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22
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Matsuda H, Fukushima N, Ichikawa H, Sawa Y. Orthotropic heart transplantation for adult congenital heart disease: a case with heterotaxy and dextrocardia. Gen Thorac Cardiovasc Surg 2015; 65:47-51. [PMID: 26162269 DOI: 10.1007/s11748-015-0573-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 06/29/2015] [Indexed: 11/29/2022]
Abstract
A 41-year-old male with heterotaxy (left isomerism) and dextrocardia composed by single ventricle, absent inferior vena cava, bilateral superior vena cava (SVC), common atrioventricular valve has received orthotopic heart transplantation (HTx) after long waiting period as Status-1. Reconstructions of bilateral SVC and hepatic vein route were successful without use of prosthetic material, and the donor heart was placed in the left mediastinum. In spite of satisfactory early recovery, the patient expired 4 months after transplantation mainly from fungal infection which developed following humoral rejection. HTx for adult patients with complex congenital heart disease is demanding in technical as well as pre- and post-transplant management, and indication should be critically determined.
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Affiliation(s)
- Hikaru Matsuda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan. .,Higashi Takarazuka Satoh Hospital, Nagaochou 2-1, Takarazuka, Hyogo, 665-0873, Japan.
| | - Norihide Fukushima
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Hajime Ichikawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan.,National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
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23
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Miana LA, Azeka E, Canêo LF, Turquetto AL, Tanamati C, Penha JG, Cauduro A, Jatene MB. Pediatric and congenital heart transplant: twenty-year experience in a tertiary Brazilian hospital. Braz J Cardiovasc Surg 2015; 29:322-9. [PMID: 25372904 PMCID: PMC4412320 DOI: 10.5935/1678-9741.20140106] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 07/10/2014] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Cardiac transplantation remains the gold standard for end-stage cardiomyopathies and congenital heart defects in pediatric patients. OBJECTIVE This study aims to report on 20 years of experience since the first case and evaluate our results. METHODS We conducted a retrospective analysis of the database and outpatient follow-up. Between October 1992 and April 2012, 109 patients underwent 114 transplants. 51.8% of them being female. The age of patients ranged from 12 days to 21 years with a mean of 8.8±5.7 years and a median of 5.2 years. The underlying diagnosis was dilated cardiomyopathy in 61.5%, congenital heart disease in 26.6% and restrictive cardiomyopathy in 11.9%. All patients above 17 years old had congenital heart disease. RESULTS Survival rate at 30 days, 1, 5, 10, 15, and 20 years were 90.4%, 81.3%, 70.9%, 60.5%, 44.4% and 26.7%, respectively. Mean cold ischemic time was 187.9 minutes and it did not correlate with mortality (P>0.05). Infectious complications and rejection episodes were the most common complications (P<0.0001), occurring, respectively, in 66% and 57.4% of the survivors after 10 years. There was no incidence of graft vascular disease and lymphoproliferative disease at year one, but they affected, respectively, 7.4% and 11% of patients within 10 years. CONCLUSION Twenty-year pediatric heart transplant results at our institution were quite satisfactory and complication rates were acceptable.
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Affiliation(s)
- Leonardo Augusto Miana
- InCor, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Estela Azeka
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Luiz Fernando Canêo
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Aída Luisa Turquetto
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Carla Tanamati
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Juliano Gomes Penha
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Alexandre Cauduro
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Marcelo Biscegli Jatene
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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Alsoufi B, Deshpande S, McCracken C, Kogon B, Vincent R, Mahle W, Kanter K. Results of heart transplantation following failed staged palliation of hypoplastic left heart syndrome and related single ventricle anomalies. Eur J Cardiothorac Surg 2015; 48:792-8; discussion 798-9. [DOI: 10.1093/ejcts/ezu547] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Accepted: 12/10/2014] [Indexed: 12/21/2022] Open
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Razzouk AJ, Bailey LL. Heart transplantation in children for end-stage congenital heart disease. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2014; 17:69-76. [PMID: 24725720 DOI: 10.1053/j.pcsu.2014.01.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Heart transplantation (HT) as primary therapy for children with congenital heart disease (CHD) has become unusual. With improved early results of reconstructive surgery, the population of children and adults surviving with CHD is expanding. End-stage CHD related to myocardial dysfunction or circulation failure after prior surgery is becoming more common as an indication for HT. This heterogeneous group of CHD recipients referred for HT presents unique decision-making, technical, and physiologic challenges. Historically, a diagnosis of CHD has been a major risk factor for early mortality after HT. Rescue HT, especially in the setting of failing Fontan physiology, has the worst outcome. Early referral (before end-organ damage), proper selection, and optimization of recipients, as well as meticulous intra- and postoperative management are crucial to improving early outcomes of HT in this population. Beyond the early post-HT period, children with end-stage CHD experience long-term survival comparable to most other non-CHD recipients.
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Affiliation(s)
- Anees J Razzouk
- Department of Cardiovascular and Thoracic Surgery, Loma Linda University Children's Hospital, Loma Linda, CA.
| | - Leonard L Bailey
- Department of Cardiovascular and Thoracic Surgery, Loma Linda University Children's Hospital, Loma Linda, CA
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Canêo LF, Miana LA, Tanamati C, Penha JG, Shimoda MS, Azeka E, Miura N, Galas FRBG, Guimarães VA, Jatene MB. Use of short-term circulatory support as a bridge in pediatric heart transplantation. Arq Bras Cardiol 2014; 104:78-84. [PMID: 25372474 PMCID: PMC4387614 DOI: 10.5935/abc.20140165] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 08/25/2014] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Heart transplantation is considered the gold standard therapy for the advanced heart failure, but donor shortage, especially in pediatric patients, is the main limitation for this procedure, so most sick patients die while waiting for the procedure. OBJECTIVE To evaluate the use of short-term circulatory support as a bridge to transplantation in end-stage cardiomyopathy. METHODS Retrospective clinical study. Between January 2011 and December 2013, 40 patients with cardiomyopathy were admitted in our Pediatric Intensive Care Unit, with a mean age of 4.5 years. Twenty patients evolved during hospitalization with clinical deterioration and were classified as Intermacs 1 and 2. One patient died within 24 hours and 19 could be stabilized and were listed. They were divided into 2 groups: A, clinical support alone and B, implantation of short-term circulatory support as bridge to transplantation additionally to clinical therapy. RESULTS We used short-term mechanical circulatory support as a bridge to transplantation in 9. In group A (n=10), eight died waiting and 2 patients (20%) were transplanted, but none was discharged. In group B (n=9), 6 patients (66.7%) were transplanted and three were discharged.The mean support time was 21,8 days (6 to 984 h). The mean transplant waiting list time was 33,8 days. Renal failure and sepsis were the main complication and cause of death in group A while neurologic complications were more prevalent en group B. CONCLUSION Mechanical circulatory support increases survival on the pediatric heart transplantation waiting list in patients classified as Intermacs 1 and 2.
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Affiliation(s)
- Luiz Fernando Canêo
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Leonardo Augusto Miana
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Carla Tanamati
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Juliano Gomes Penha
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Monica Satsuki Shimoda
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Estela Azeka
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Nana Miura
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | - Vanessa Alves Guimarães
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Marcelo Biscegli Jatene
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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Murtuza B, Fenton M, Burch M, Gupta A, Muthialu N, Elliott MJ, Hsia TY, Tsang VT, Kostolny M. Pediatric heart transplantation for congenital and restrictive cardiomyopathy. Ann Thorac Surg 2013; 95:1675-84. [PMID: 23561807 DOI: 10.1016/j.athoracsur.2013.01.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Revised: 01/06/2013] [Accepted: 01/08/2013] [Indexed: 01/15/2023]
Abstract
BACKGROUND Recent reports suggest worse outcomes in pediatric orthotopic heart transplantation (OHT) for congenital heart disease (CHD) and restrictive cardiomyopathy (RCM). We examined early outcomes in these diverse groups of patients in comparison with patients with dilatated cardiomyopathy (DCM). METHODS From 2000 to 2011, 209 patients were included: 50 with CHD, 23 with RCM, and 136 with DCM. Early survival was studied, as was the occurrence of acute rejection, donor-specific antibodies (DSAs) and nondonor-specific antibodies (NSDAs), incidence of pulmonary hypertension (PHT), right ventricular failure (RVF), and the need for mechanical circulatory support (MCS). RESULTS The incidence of preoperative PHT was greatest in the RCM group (χ(2)p = 0.0006); the requirement for mechanical support before OHT was greatest in patients with DCM. Thirty-day survival was 92.0%, 97.1%, and 100% for patients with CHD, DCM, and RCM respectively. The incidence of RVF was highest for patients with RCM (43.5%; versus CHD, 26.0%; versus DCM, 14.7%). One-year survival estimates for patients with CHD, DCM, and RCM were 92.0%, 97.8%, and 82.6%, respectively (log-rank p = 0.165). Multivariable analysis revealed 4 significant risk factors for mortality: age, incidence of acute rejection, preoperative PHT, and the presence of NDSAs. The occurrence of DSAs was similar, although there was a significantly higher incidence of NDSAs in the CHD and RCM groups (36.0% and 30.4%, respectively, versus 14.0% in the DCM group; χ(2)p = 0.0024). CONCLUSIONS Equivalent outcomes are achievable in pediatric OHT despite marked heterogeneity in anatomic and physiologic complexity in recipients. Physiologic factors such as PHT are likely to be more important than anatomic complexities in determining survival. The potential relevance of NDSAs warrants further investigation.
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Affiliation(s)
- Bari Murtuza
- Department of Cardiac Surgery, Great Ormond Street Hospital for Children, London, United Kingdom
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Impact of Single-Ventricle Physiology on Death After Heart Transplantation in Adults With Congenital Heart Disease. Ann Thorac Surg 2012; 94:1281-7; discussion 1287-8. [DOI: 10.1016/j.athoracsur.2012.05.075] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2012] [Revised: 05/15/2012] [Accepted: 05/21/2012] [Indexed: 11/21/2022]
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Heart cells with regenerative potential from pediatric patients with end stage heart failure: a translatable method to enrich and propagate. Stem Cells Int 2012; 2012:452102. [PMID: 22936950 PMCID: PMC3425869 DOI: 10.1155/2012/452102] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2012] [Revised: 06/22/2012] [Accepted: 06/29/2012] [Indexed: 11/17/2022] Open
Abstract
Background. Human cardiac-derived progenitor cells (hCPCs) have shown promise in treating heart failure (HF) in adults. The purpose of this study was to describe derivation of hCPCs from pediatric patients with end-stage HF. Methods. At surgery, discarded right atrial tissues (hAA) were obtained from HF patients (n = 25; hAA-CHF). Minced tissues were suspended in complete (serum-containing) DMEM. Cells were selected for their tissue migration and expression of stem cell factor receptor (hc-kit). Characterization of hc-kit(positive) cells included immunohistochemical screening with a panel of monoclonal antibodies. Results. Cells, including phase-bright cells identified as hc-kit(positive), spontaneously emigrated from hAA-CHF in suspended explant cultures (SEC) after Day 7. When cocultured with tissue, emigrated hc-kit(positive) cells proliferated, first as loosely attached clones and later as multicellular clusters. At Day 21~5% of cells were hc-kit(positive). Between Days 14 and 28 hc-kit(positive) cells exhibited mesodermal commitment (GATA-4(positive) and NKX2.5(positive)); then after Day 28 cardiac lineages (flk-1(positive), smooth muscle actin(positive), troponin-I(positive), and myosin light chain(positive)). Conclusions. C-kit(positive) hCPCs can be derived from atrial tissue of pediatric patients with end-stage HF. SEC is a novel culture method for derivation of migratory hc-kit(positive) cells that favors clinical translation by reducing the need for exogenously added factors to expand hCPCs in vitro.
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Murtuza B, Dedieu N, Vazquez A, Fenton M, Burch M, Hsia TY, Tsang VT, Kostolny M. Results of orthotopic heart transplantation for failed palliation of hypoplastic left heart†. Eur J Cardiothorac Surg 2012; 43:597-603. [DOI: 10.1093/ejcts/ezs326] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Abstract
Highly sensitised children in need of cardiac transplantation have overall poor outcomes because of increased risk for dysfunction of the cardiac allograft, acute cellular and antibody-mediated rejection, and vasculopathy of the cardiac allograft. Cardiopulmonary bypass and the frequent use of blood products in the operating room and cardiac intensive care unit, as well as the frequent use of homografts, have predisposed potential recipients of transplants to allosensitisation. The expansion in the use of ventricular assist devices and extracorporeal membrane oxygenation has also contributed to increasing rates of allosensitisation in candidates for cardiac transplantation. Antibodies to Human Leukocyte Antigen can be detected before transplantation using several different techniques, the most common being the "complement-dependent lymphocytotoxicity assays". "Solid-phase assays", particularly the "Luminex® single antigen bead method", offer improved specificity and more detailed information regarding specificities of antibodies, leading to improved matching of donors with recipients. Allosensitisation prolongs the time on the waiting list for potential recipients of transplantation and increases the risk of complications and death after transplantation. Aggressive reduction of antibodies to Human Leukocyte Antigen in these high-risk patients is therefore of vital importance for long-term survival of the patient and cardiac allograft. Strategies to decrease Panel Reactive Antibody or percent reactive antibody before transplantation include plasmapheresis, intravenous administration of immunoglobulin, and specific treatment to reduce B-cells, particularly Rituximab. These strategies have resulted in varying degrees of success. Antibody-mediated rejection and cardiac allograft vasculopathy are two of the most important complications of transplantation in patients with high Panel Reactive Antibody. The treatment of antibody-mediated rejection in recipients of cardiac transplants is largely empirical and includes the use of high-dose corticosteroids, plasmapheresis, intravenous administration of immunoglobulins, anti-thymocyte globulin, and Rituximab. Cardiac allograft vasculopathy is believed to be secondary to chronic complement-mediated endothelial injury and chronic vascular rejection. The use of proliferation signal inhibitors, such as sirolimus and everolimus, has been shown to delay the progression of cardiac allograft vasculopathy. In some non-sensitised recipients of cardiac transplants, the de novo formation of antibodies to Human Leukocyte Antigen after transplantation may increase the likelihood of adverse clinical outcomes. The use of serial testing for donor-specific antibodies after cardiac transplantation may be advisable in patients with frequent episodes of rejection and patients with history of sensitisation. Allosensitisation before transplantation can negatively influence outcomes after transplantation. A high incidence of antibody-mediated rejection and graft vasculopathy can result in graft failure and decreased survival. Current strategies to decrease allosensitisation have helped to expand the pool of donors, improve times on the waiting list, and decrease mortality. Centres of transplantation offering desensitisation are currently using plasmapheresis to remove circulating antibodies; intravenous immunoglobulin to inactivate antibodies; cyclophosphamide to suppress B-cell proliferation; and Rituximab to deplete B-lymphocytes. Similar approaches are also used to treat antibody-mediated rejection after transplantation with promising results.
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Jacobs JP, Pasquali SK, Morales DLS, Jacobs ML, Mavroudis C, Chai PJ, Tchervenkov CI, Lacour-Gayet FG, Walters H, Quintessenza JA. Heterotaxy: lessons learned about patterns of practice and outcomes from the congenital heart surgery database of the society of thoracic surgeons. World J Pediatr Congenit Heart Surg 2011; 2:278-86. [PMID: 23804985 PMCID: PMC3695419 DOI: 10.1177/2150135110397670] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
According to The International Society for Nomenclature of Pediatric and Congenital Heart Disease (ISNPCHD), "Heterotaxy is synonymous with 'visceral heterotaxy' and 'heterotaxy syndrome'. Heterotaxy is defined as an abnormality where the internal thoraco-abdominal organs demonstrate abnormal arrangement across the left-right axis of the body. By convention, heterotaxy does not include patients with either the expected usual or normal arrangement of the internal organs along the left-right axis, also known as 'situs solitus', or patients with complete mirror-imaged arrangement of the internal organs along the left-right axis also known as `situs inversus'." or patients with complete mirror-image arrangement of the internal organs along the left-right axis, also known as situs inversus. The purpose of this article is to review the data about heterotaxy in the Society of Thoracic Surgeons (STS) Congenital Heart Surgery Database. The investigators examined all index operations in the STS Congenital Heart Surgery Database over 12 years from January 1, 1998 to December 31, 2009, inclusive. This analysis resulted in a cohort of 77 153 total index operations. Of these, 1505 operations (1.95%) were performed in patients with heterotaxy. Of the 1505 index operations performed in patients with heterotaxy, 1144 were in patients with asplenia and 361 were in patients with polysplenia. In every STS -EACTS Congenital Heart Surgery Mortality Category, discharge mortality is higher in patients with heterotaxy compared with patients without heterotaxy (EACTS = European Association for Cardio-Thoracic Surgery). Discharge mortality after systemic to pulmonary artery shunt is 6.6% in a cohort of all single-ventricle patients except those with heterotaxy, whereas it is 10.8% in single-ventricle patients with heterotaxy. Discharge mortality after Fontan is 1.8% in a cohort of all single-ventricle patients except those with heterotaxy, whereas it is 4.2% in single-ventricle patients with heterotaxy. The STS Congenital Heart Surgery Database is largest congenital heart surgery database in North America. This review of data from the STS Congenital Heart Surgery Database allows for unique documentation of practice patterns and outcomes. From this analysis, it is clear that heterotaxy is a challenging problem with increased discharge mortality in most subgroups.
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Affiliation(s)
- Jeffrey Phillip Jacobs
- The Congenital Heart Institute of Florida (CHIF), All Children's Hospital and Children's Hospital of Tampa, University of South Florida College of Medicine, Cardiac Surgical Associates of Florida (CSAoF), Saint Petersburg and Tampa, FL, USA
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