1
|
Khan MA, Lau CL, Krupnick AS. Monitoring regulatory T cells as a prognostic marker in lung transplantation. Front Immunol 2023; 14:1235889. [PMID: 37818354 PMCID: PMC10561299 DOI: 10.3389/fimmu.2023.1235889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 09/11/2023] [Indexed: 10/12/2023] Open
Abstract
Lung transplantation is the major surgical procedure, which restores normal lung functioning and provides years of life for patients suffering from major lung diseases. Lung transplant recipients are at high risk of primary graft dysfunction, and chronic lung allograft dysfunction (CLAD) in the form of bronchiolitis obliterative syndrome (BOS). Regulatory T cell (Treg) suppresses effector cells and clinical studies have demonstrated that Treg levels are altered in transplanted lung during BOS progression as compared to normal lung. Here, we discuss levels of Tregs/FOXP3 gene expression as a crucial prognostic biomarker of lung functions during CLAD progression in clinical lung transplant recipients. The review will also discuss Treg mediated immune tolerance, tissue repair, and therapeutic strategies for achieving in-vivo Treg expansion, which will be a potential therapeutic option to reduce inflammation-mediated graft injuries, taper the toxic side effects of ongoing immunosuppressants, and improve lung transplant survival rates.
Collapse
|
2
|
Stephens EH, Tannous P, Mongé MC, Eltayeb O, Devlin PJ, Backer CL, Forbess JM, Pahl E. Normalization of hemodynamics is delayed in patients with a single ventricle after pediatric heart transplantation. J Thorac Cardiovasc Surg 2020; 159:1986-1996. [DOI: 10.1016/j.jtcvs.2019.09.135] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 09/04/2019] [Accepted: 09/09/2019] [Indexed: 10/25/2022]
|
3
|
van der Mheen M, van der Meulen MH, den Boer SL, Schreutelkamp DJ, van der Ende J, de Nijs PFA, Breur JMPJ, Tanke RB, Blom NA, Rammeloo LAJ, ten Harkel ADJ, du Marchie Sarvaas GJ, Utens EMWJ, Dalinghaus M. Emotional and behavioral problems in children with dilated cardiomyopathy. Eur J Cardiovasc Nurs 2020; 19:291-300. [PMID: 31552760 PMCID: PMC7153220 DOI: 10.1177/1474515119876148] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 07/25/2019] [Accepted: 08/23/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Dilated cardiomyopathy (DCM) in children is an important cause of severe heart failure and carries a poor prognosis. Adults with heart failure are at increased risk of anxiety and depression and such symptoms predict adverse clinical outcomes such as mortality. In children with DCM, studies examining these associations are scarce. AIMS We studied whether in children with DCM: (1) the level of emotional and behavioral problems was increased as compared to normative data, and (2) depressive and anxiety problems were associated with the combined risk of death or cardiac transplantation. METHODS To assess emotional and behavioral problems in children with DCM, parents of 68 children, aged 1.5-18 years (6.9±5.7 years), completed the Child Behavior Checklist. RESULTS Compared to normative data, more young children (1.5-5 years) with DCM had somatic complaints (24.3% vs. 8.0%; p < .001), but fewer had externalizing problems (5.4% vs. 17.0%; p = .049). Overall internalizing problems did not reach significance. Compared to normative data, more older children (6-18 years) showed internalizing problems (38.7% vs. 17.0%; p = .001), including depressive (29.0% vs. 8.0%; p < .001) and anxiety problems (19.4% vs. 8.0%; p = .023), and somatic complaints (29.0% vs. 8.0%; p < .001). Anxiety and depressive problems, corrected for heart failure severity, did not predict the risk of death or cardiac transplantation. CONCLUSION Children of 6 years and older showed more depressive and anxiety problems than the normative population. Moreover, in both age groups, somatic problems were common. No association with outcome could be demonstrated.
Collapse
Affiliation(s)
- Malindi van der Mheen
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC – Sophia Children’s Hospital, Rotterdam, The Netherlands
| | | | - Susanna L den Boer
- Department of Pediatrics, Erasmus MC – Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Dayenne J Schreutelkamp
- Department of Pediatric Intensive Care, Erasmus MC – Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Jan van der Ende
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC – Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Pieter FA de Nijs
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC – Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Johannes MPJ Breur
- Department of Pediatrics, Wilhelmina Children’s Hospital, UMC Utrecht, The Netherlands
| | - Ronald B Tanke
- Department of Pediatrics, Radboud UMC, Nijmegen, The Netherlands
| | - Nico A Blom
- Department of Pediatrics, Amsterdam UMC, Emma Children’s Hospital, The Netherlands
| | - Lukas AJ Rammeloo
- Department of Pediatrics, Amsterdam UMC, VU University Medical Center, The Netherlands
| | | | | | - Elisabeth MWJ Utens
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC – Sophia Children’s Hospital, Rotterdam, The Netherlands
- Research Institute of Child Development and Education, University of Amsterdam, The Netherlands
- Academic Centre for Child and Adolescent Psychiatry the Bascule, Amsterdam UMC, Academic Medical Centre, The Netherlands
| | - Michiel Dalinghaus
- Department of Pediatrics, Erasmus MC – Sophia Children’s Hospital, Rotterdam, The Netherlands
| |
Collapse
|
4
|
Pellikka PA, Arruda-Olson A, Chaudhry FA, Chen MH, Marshall JE, Porter TR, Sawada SG. Guidelines for Performance, Interpretation, and Application of Stress Echocardiography in Ischemic Heart Disease: From the American Society of Echocardiography. J Am Soc Echocardiogr 2020; 33:1-41.e8. [DOI: 10.1016/j.echo.2019.07.001] [Citation(s) in RCA: 124] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
5
|
Valdeomillos E, Jalal Z, Metras A, Roubertie F, Benoist D, Bernus O, Haïssaguerre M, Bordachar P, Iriart X, Thambo JB. Animal Models of Repaired Tetralogy of Fallot: Current Applications and Future Perspectives. Can J Cardiol 2019; 35:1762-1771. [PMID: 31711822 DOI: 10.1016/j.cjca.2019.07.622] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 06/17/2019] [Accepted: 07/03/2019] [Indexed: 10/26/2022] Open
Abstract
Tetralogy of Fallot is the most common cyanotic congenital heart disease. Despite ongoing improvements in the initial surgical repair, there are lingering concerns regarding the long-term outcomes that may be complicated by right ventricular dysfunction, right ventricular dyssynchrony, and sudden cardiac death. The mechanisms leading to these late complications remain incompletely understood. Experimental animal models have been developed as preclinical steps to gain better insight into the pathophysiology of diseases and to develop new therapeutic strategies. This article summarizes the various types of experimental animal models of repaired tetralogy of Fallot published to date in the literature, with the aim of achieving a greater understanding of the deleterious mechanisms that may lead to these known late and sometimes lethal complications. In addition to analysing the type of animals that can be used according to a given study's objectives, needs, and constraints, the present review also evaluates the type of dysfunction that can be reproduced in our model according to the research objectives, as well as the different types of studies in which these models can be used. In view of all that, we propose a decision algorithm to create an animal model of repaired tetralogy of Fallot. This synthesis should furthermore help in the development of future studies and in the design of new experimental models, thus allowing greater insight into this disease, while not forgetting the ultimate goal of broadening future therapeutic measures to reduce the morbidity and mortality of this prevalent congenital heart disease.
Collapse
Affiliation(s)
- Estibaliz Valdeomillos
- Department of Pediatric and Adult Congenital Cardiology, Bordeaux University Hospital (CHU), Bordeaux, France; IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France; INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France.
| | - Zakaria Jalal
- Department of Pediatric and Adult Congenital Cardiology, Bordeaux University Hospital (CHU), Bordeaux, France; IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France; INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Alexandre Metras
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France; INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France; Department of Pediatric and Adult Congenital Surgery, Bordeaux University Hospital (CHU), Bordeaux, France
| | - François Roubertie
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France; INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France; Department of Pediatric and Adult Congenital Surgery, Bordeaux University Hospital (CHU), Bordeaux, France
| | - David Benoist
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France; INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Olivier Bernus
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France; INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Michel Haïssaguerre
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France; INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France; Department of Electrophysiology, Cardio-Thoracic Unit, Bordeaux University Hospital (CHU), Bordeaux, France
| | - Pierre Bordachar
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France; INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France; Department of Electrophysiology, Cardio-Thoracic Unit, Bordeaux University Hospital (CHU), Bordeaux, France
| | - Xavier Iriart
- Department of Pediatric and Adult Congenital Cardiology, Bordeaux University Hospital (CHU), Bordeaux, France; IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France; INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Jean-Benoit Thambo
- Department of Pediatric and Adult Congenital Cardiology, Bordeaux University Hospital (CHU), Bordeaux, France; IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France; INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| |
Collapse
|
6
|
Ting M, Tsao CI, Wang CH, Chi NH, Huang SC, Chou NK, Chen YS, Wang SS. Survival Outcomes of Oversized Cardiac Allografts in Pediatric Patients-A Single-Center Experience in Taiwan. Transplant Proc 2018; 50:2747-2750. [PMID: 30401389 DOI: 10.1016/j.transproceed.2018.02.195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 02/26/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVES An oversized cardiac allograft may have a negative impact on survival outcomes according to previous studies; however, due to the shortage of pediatric donor hearts, the use of oversized cardiac allografts is sometimes inevitable. In this study, we reported the survival outcomes of pediatric patients in relation with the donor-recipient weight ratio. METHODS Twenty-eight children, aged 3 months to 17 years, with dilated cardiomyopathy underwent primary cardiac transplantation at the National Taiwan University Hospital between 1995 and 2012. We analyzed these patients according to the donor-recipient weight ratio: group 1 (n = 19) with donor-recipient weight ratio <2.5 (median 1.1, interquartile range 1.0-1.6), and group 2 (n = 9) with donor-recipient weight ratio ≥2.5 (median 3.0, inter-quartile range 2.87-3.5). RESULTS The 30-day survival rate was 100% for both group 1 and group 2 (P = 1). The survival rates for group 1 and group 2 were 95% vs 100% at 1 year, 84% vs 89% at 5 years, and 73% vs 61% at 10 years. The median survival was 14.4 years vs 12.9 years (P = .6313). CONCLUSION In this cohort, the use of oversized cardiac allograft in pediatric patients for dilated cardiomyopathy did not have a negative effect on short-term and long-term survival.
Collapse
Affiliation(s)
- M Ting
- Department of Surgery, National Taiwan University Hospital, and National Taiwan University College of Medicine, Taipei, Taiwan
| | - C-I Tsao
- Department of Surgery, National Taiwan University Hospital, and National Taiwan University College of Medicine, Taipei, Taiwan
| | - C-H Wang
- Department of Surgery, National Taiwan University Hospital, and National Taiwan University College of Medicine, Taipei, Taiwan
| | - N-H Chi
- Department of Surgery, National Taiwan University Hospital, and National Taiwan University College of Medicine, Taipei, Taiwan
| | - S-C Huang
- Department of Surgery, National Taiwan University Hospital, and National Taiwan University College of Medicine, Taipei, Taiwan
| | - N-K Chou
- Department of Surgery, National Taiwan University Hospital, and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Y-S Chen
- Department of Surgery, National Taiwan University Hospital, and National Taiwan University College of Medicine, Taipei, Taiwan
| | - S-S Wang
- Department of Surgery, National Taiwan University Hospital, and National Taiwan University College of Medicine, Taipei, Taiwan; Department of Surgery, Fu Jen Catholic University Hospital, and Fu Jen Catholic University College of Medicine, New Taipei City, Taiwan.
| |
Collapse
|
7
|
Fadl S, Wåhlander H, Fall K, Cao Y, Sunnegårdh J. The highest mortality rates in childhood dilated cardiomyopathy occur during the first year after diagnosis. Acta Paediatr 2018; 107:672-677. [PMID: 29224255 PMCID: PMC5887975 DOI: 10.1111/apa.14183] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 09/15/2017] [Accepted: 12/05/2017] [Indexed: 11/29/2022]
Abstract
Aim The aim of the study was to assess the incidence, mortality and morbidity of dilated cardiomyopathy (DCM) and noncompaction of the left ventricle (LVNC) in Swedish children. Methods We reviewed hospital records of all children with dilated cardiomyopathy (DCM) or left ventricular noncompaction cardiomyopathy (LVNC) up to the age of 18 in the healthcare region of western Sweden from 1991 to 2015. Results In total, 69 cases (61% males) were identified. The combined incidence of DCM and LVNC was 0.77 (95% CI 0.59‐0.96) per 100 000 person years. Children were divided into six groups, and their outcomes were analysed depending on their aetiology. Idiopathic DCM was reported in 43%, and familial dilated and left ventricular noncompaction aetiology was present in 32%. DCM due to various diseases occurred in 8%. DCM associated with neuromuscular diseases was present in 16%. The overall risk of death or receiving transplants in children with idiopathic and familial DCM was 30% over the study period, and 21% died in the first year after diagnosis. Conclusion The combined incidence of DCM and LVNC was similar to previous reports. Most children with idiopathic DCM presented during infancy, and mortality was highest during the first year after diagnosis.
Collapse
Affiliation(s)
- Shalan Fadl
- Department of Paediatrics; Örebro University Hospital; Örebro Sweden
| | - Håkan Wåhlander
- The Queen Silvia Children's Hospital; Sahlgrenska University Hospital; Institution of Clinical Sciences; Gothenburg University; Gothenburg Sweden
| | - Katja Fall
- Clinical Epidemiology and Biostatistics; School of Medical Sciences; Örebro University; Örebro Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics; School of Medical Sciences; Örebro University; Örebro Sweden
- Unit of Biostatistics; Institute of Environmental Medicine; Karolinska Institutet; Stockholm Sweden
| | - Jan Sunnegårdh
- The Queen Silvia Children's Hospital; Sahlgrenska University Hospital; Institution of Clinical Sciences; Gothenburg University; Gothenburg Sweden
| |
Collapse
|
8
|
Abstract
Heart transplantation in pediatric patients generally arises as a treatment option of last resort, that is, the indication is for patients with heart failure of various etiologies, with potential or actual end-organ dysfunction, in whom there are no reasonable, long-term options for life-prolonging therapy. The concept of heart failure is complex in a pediatric population, particularly those with congenital heart disease. While heart failure may refer simply to systolic dysfunction leading to low cardiac output, it can also encompass: diastolic dysfunction in restrictive cardiomyopathy; single ventricle physiology without an option for stable palliation. A good candidate should have a predicted life expectancy less than the median lifetime of a transplanted heart. Significant improvement in survival has been observed over time with 1- and 5-year survival approximately 90% and 80% in the contemporary era.
Collapse
Affiliation(s)
- Thomas D Ryan
- Division of Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave-MLC 2003, Cincinnati, Ohio 45229
| | - Clifford Chin
- Division of Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave-MLC 2003, Cincinnati, Ohio 45229.
| |
Collapse
|
9
|
Chanana N, Van Dorn CS, Everitt MD, Weng HY, Miller DV, Menon SC. Alteration of Cardiac Deformation in Acute Rejection in Pediatric Heart Transplant Recipients. Pediatr Cardiol 2017; 38:691-699. [PMID: 28161809 DOI: 10.1007/s00246-016-1567-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 12/30/2016] [Indexed: 11/28/2022]
Abstract
The objective of this study is to assess changes in cardiac deformation during acute cellular- and antibody-mediated rejection in pediatric HT recipients. Pediatric HT recipients aged ≤18 years with at least one episode of biopsy-diagnosed rejection from 2006 to 2013 were included. Left ventricular systolic S (SS) and SR (SSr) data were acquired using 2D speckle tracking on echocardiograms obtained within 12 h of right ventricular endomyocardial biopsy. A mixed effect model was used to compare cardiac deformation during CR (Grade ≥ 1R), AMR (pAMR ≥ 2), and mixed rejection (CR and AMR positive) versus no rejection (Grade 0R and pAMR 0 or 1). A total of 20 subjects (10 males, 50%) with 71 rejection events (CR 35, 49%; AMR 21, 30% and mixed 15, 21%) met inclusion criteria. The median time from HT to first biopsy used for analysis was 5 months (IQR 0.25-192 months). Average LV longitudinal SS and SSr were reduced significantly during rejection (SS: -17.2 ± 3.4% vs. -10.7 ± 4.5%, p < 0.001 and SSr: -1.2 ± 0.2 s- 1 vs. -0.9 ± 0.3 s- 1; p < 0.001) and in all rejection types. Average LV short-axis radial SS was reduced only in CR compared to no rejection (p = 0.04), while average LV circumferential SS and SSr were reduced significantly in AMR compared to CR (SS: 18.9 ± 4.2% vs. 20.8 ± 8.8%, p = 0.03 and SSr: 1.35 ± 0.8 s- 1 vs. 1.54 ± 0.9 s- 1; p = 0.03). In pediatric HT recipients, LV longitudinal SS and SSr were reduced in all rejection types, while LV radial SS was reduced only in CR. LV circumferential SS and SSr further differentiated between CR and AMR with a significant reduction seen in AMR as compared to CR. This novel finding suggests mechanistic differences between AMR- and CR-induced myocardial injury which may be useful in non-invasively predicting the type of rejection in pediatric HT recipients.
Collapse
Affiliation(s)
- Nitin Chanana
- Pediatric Cardiology, Children's Heart Center of El Paso, El Paso, TX, USA
| | - Charlotte S Van Dorn
- Division of Critical Care and Pediatric Cardiology, Department of Pediatrics, Mayo Clinic, Rochester, MN, USA
| | - Melanie D Everitt
- Division of Cardiology, Department of Pediatrics, Children's Hospital Colorado, Aurora, CO, USA
| | - Hsin Yi Weng
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, 81 N. Mario Capecchi Drive, Salt Lake City, UT, 84113, USA
| | - Dylan V Miller
- Department of Pathology, University of Utah, Salt Lake City, UT, USA
| | - Shaji C Menon
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, 81 N. Mario Capecchi Drive, Salt Lake City, UT, 84113, USA.
| |
Collapse
|
10
|
Aggarwal S, Blake J, Sehgal S. Right Ventricular Dysfunction as an Echocardiographic Measure of Acute Rejection Following Heart Transplantation in Children. Pediatr Cardiol 2017; 38:442-447. [PMID: 27878627 DOI: 10.1007/s00246-016-1533-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 11/12/2016] [Indexed: 11/26/2022]
Abstract
Noninvasive biomarkers of acute allograft rejection (AAR) following orthotopic heart transplantation (OHT) are needed. The aim of this study was to investigate the accuracy of echocardiographic (ECHO) right ventricular (RV) global functional and resistance indices in the detection of AAR. This retrospective chart review included children with biopsy-proven AAR (grade ≥ 2R cellular or CD4 + antibody-mediated rejection) following OHT and an ECHO within 12 h of the biopsy. ECHO measures: (a) ratio of systolic to diastolic duration (S/D), (b) RV myocardial performance index (MPI) and (c) tricuspid regurgitant gradient to RV outflow tract velocity time integral ratio (TRG/VTI), were derived at baseline, during AAR and at two follow-ups. Sixteen patients [56% male, mean (SD) age at OHT 3.5 (4.3) years] had 16 AAR episodes. S/D (1.15 vs. 1.60, p < 0.01), RV MPI (0.19 vs. 0.39, p < 0.01) and TRG/VTI (1.05 vs. 1.7, p = 0.01) deteriorated during AAR and, except for diastolic duration, improved significantly at first follow-up. The negative predictive values for S/D, RV MPI and TRG/VTI at cutoffs of 1.3, 0.31 and 1.3 were 97, 97 and 87%, respectively. RV S/D, MPI and TRG/VTI deteriorated during AAR. Their excellent negative predictive values suggest that their incorporation in surveillance may obviate the need for routine biopsies.
Collapse
Affiliation(s)
- Sanjeev Aggarwal
- Division of Pediatric Cardiology, Children's Hospital of Michigan, Detroit, MI, USA.
| | - Jennifer Blake
- Division of Pediatric Cardiology, Children's Hospital of Michigan, Detroit, MI, USA
| | - Swati Sehgal
- Division of Pediatric Cardiology, Children's Hospital of Michigan, Detroit, MI, USA
| |
Collapse
|
11
|
Abstract
OBJECTIVES Although there have been tremendous advancements in the care of severe pediatric cardiovascular disease, heart transplantation remains the standard therapy for end-stage heart disease in children. As such, these patients comprise an important and often complex subset of patients in the ICU. The purpose of this article is to review the causes and management of allograft dysfunction and the medications used in the transplant population. DATA SOURCES MEDLINE, PubMed, and Cochrane Database of systemic reviews. CONCLUSIONS Pediatric heart transplant recipients represent a complex group of patients that frequently require critical care. Their immunosuppressive medications, while being vital to maintenance of allograft function, are associated with significant short- and long-term complications. Graft dysfunction can occur from a variety of etiologies at different times following transplantation and remains a major limitation to long-term posttransplant survival.
Collapse
|
12
|
Green A, McSweeney J, Ainley K, Bryant J. In My Shoes: Children's Quality of Life after Heart Transplantation. Prog Transplant 2016; 17:199-207; quiz 208. [DOI: 10.1177/152692480701700307] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Although heart transplantation has been offered for 2 decades to prolong the lives of children with end-stage heart disease, we know little about how these children view their lives, how they deal with their complicated medical regimen, and how the transplantation affects their quality of life. Objectives To examine the quality of life of school-aged heart transplant recipients and to identify the key factors they believe affect their quality of life. Design Focused ethnography. Participants and Setting Eleven children (7 girls, 4 boys) between the ages of 6 and 12 years (mean 9.1 years) who had received a transplant at least 6 months earlier were recruited from a large children's hospital. Data Collection and Analysis Semistructured interviews were conducted in private locations. Data were analyzed using content analysis and constant comparison. Results The children described their quality of life as “mostly good,” yet reported that life was “easy and not easy.” Ten factors that affected the children's quality of life were Doing Things/Going Places, Favorite School Activities, Hard Things About School, Being With Friends and Family, Doing Things/Going Places With Friends and Family, Interactions With Friends and Family, Taking Care of My Heart, My Body, The Transplant Team, and Other Health Problems. Based on similarities in meaning, these factors were combined into 3 themes: Doing What Kids Do, Being With Friends and Family, and Being a Heart Transplant Kid. The themes and factors can provide useful direction for interventions aimed at improving the quality of life for children after heart transplantation.
Collapse
Affiliation(s)
- Angela Green
- Arkansas Children's Hospital, Little Rock, AR (AG, KA, JB), University of Arkansas for Medical Sciences, Little Rock (AG, JM, KA, JB)
| | - Jean McSweeney
- Arkansas Children's Hospital, Little Rock, AR (AG, KA, JB), University of Arkansas for Medical Sciences, Little Rock (AG, JM, KA, JB)
| | - Kathy Ainley
- Arkansas Children's Hospital, Little Rock, AR (AG, KA, JB), University of Arkansas for Medical Sciences, Little Rock (AG, JM, KA, JB)
| | - Janet Bryant
- Arkansas Children's Hospital, Little Rock, AR (AG, KA, JB), University of Arkansas for Medical Sciences, Little Rock (AG, JM, KA, JB)
| |
Collapse
|
13
|
Lui C, Grimm JC, Magruder JT, Dungan SP, Spinner JA, Do N, Nelson KL, Cameron DE, Vricella LA, Jacobs ML. The Effect of Institutional Volume on Complications and Their Impact on Mortality After Pediatric Heart Transplantation. Ann Thorac Surg 2015; 100:1423-31. [PMID: 26298167 DOI: 10.1016/j.athoracsur.2015.06.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 04/06/2015] [Accepted: 06/01/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND This study evaluated the potential association of institutional volume with survival and mortality subsequent to major complications in a modern cohort of pediatric patients after orthotopic heart transplantation (OHT). METHODS The United Network of Organ Sharing database was queried for pediatric patients (aged ≤18 years) undergoing OHT between 2000 and 2010. Institutional volume was defined as the average number of transplants completed annually during each institution's active period and was evaluated as categoric and as a continuous variable. Logistic regression models were used to determine the effect of institutional volumes on postoperative outcomes, which included renal failure, stroke, rejection, reoperation, infection, and a composite complication outcome. Cox modeling was used to analyze the risk-adjusted effect of institutional volume on 30-day, 1-year, and 5-year mortality. Kaplan-Meier estimates were used to compare differences in unconditional survival. RESULTS A total of 3,562 patients (111 institutions) were included and stratified into low-volume (<6.5 transplants/year, 91 institutions), intermediate-volume (6.5 to 12.5 transplants/year, 12 institutions), and high-volume (>12.5 transplants/year, 8 institutions) tertiles. Unadjusted survival was significantly different at 30 days (p = 0.0087) in the low-volume tertile (94.2%; 95% confidence interval, 92.7% to 95.4%) compared with the high-volume tertile (96.8%; 95% confidence interval, 95.7% to 97.7%). No difference was observed at 1 or 5 years. Risk-adjusted Cox modeling demonstrated that low-volume institutions had an increased rate of mortality at 30 days (hazard ratio, 1.91; 95% confidence interval, 1.02 to 3.59; p = 0.044), but not at 1 or 5 years. High-volume institutions had lower incidences of postoperative complications than low-volume institutions (30.3% vs 38.4%, p < 0.001). Despite this difference in the rate of complications, survival in patients with a postoperative complication was similar across the volume tertiles. CONCLUSIONS No association was observed between institutional volume and adjusted or unadjusted long-term survival. High-volume institutions have a significantly lower rate of postoperative complications after pediatric OHT. This association does not correlate with increased subsequent mortality in low-volume institutions. Given these findings, strategies integral to the allocation of allografts in adult transplantation, such as regionalization of care, may not be as relevant to pediatric OHT.
Collapse
Affiliation(s)
- Cecillia Lui
- Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Joshua C Grimm
- Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - J Trent Magruder
- Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Samuel P Dungan
- Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Joseph A Spinner
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Nhue Do
- Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Kristin L Nelson
- Division of Pediatric Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Duke E Cameron
- Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Luca A Vricella
- Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Marshall L Jacobs
- Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Maryland.
| |
Collapse
|
14
|
Cifra B, Dragulescu A, Border WL, Mertens L. Stress echocardiography in paediatric cardiology. Eur Heart J Cardiovasc Imaging 2015; 16:1051-9. [DOI: 10.1093/ehjci/jev159] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 05/25/2015] [Indexed: 01/08/2023] Open
|
15
|
Schweiger M, Stiasny B, Dave H, Cavigelli-Brunner A, Balmer C, Kretschmar O, Bürki C, Klauwer D, Hübler M. Pediatric heart transplantation. J Thorac Dis 2015; 7:552-9. [PMID: 25922739 DOI: 10.3978/j.issn.2072-1439.2015.01.38] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Accepted: 11/25/2014] [Indexed: 11/14/2022]
Abstract
Pediatric heart transplantation (pHTx) represents a small (14%) but very important and particular part in the field of cardiac transplantation. This treatment has lifelong impact on children. To achieve the best short and especially long-term survival with adequate quality of life, which is of crucial importance for this young patient population, one has to realize and understand the differences with adult HTx. Indication for transplantation, waitlist management including ABO incompatible (ABOi) transplantation and immunosuppression differ. Although young transplant recipients are ultimately likely to be considered for re-transplantation. One has to distinguish between myopathy and complex congenital heart disease (CHD). The differences in anatomy and physiology make the surgical procedure much more complex and create unique challenges. These recipients need a well-organized and educated team with pediatric cardiologists and intensivists, including a high skilled surgeon, which is dedicated to pHTx. Therefore, these types of transplants are best concentrated in specialized centers to achieve promising outcome.
Collapse
Affiliation(s)
- Martin Schweiger
- 1 Department for Congenital Cardiovascular Surgery, 2 Divisions of Pediatric Cardiology and Children's Research Centre, 3 Department for Anesthesiology, 4 Department of Intensive Care and Neonatology, University Children's Hospital, Zurich, Switzerland
| | - Brian Stiasny
- 1 Department for Congenital Cardiovascular Surgery, 2 Divisions of Pediatric Cardiology and Children's Research Centre, 3 Department for Anesthesiology, 4 Department of Intensive Care and Neonatology, University Children's Hospital, Zurich, Switzerland
| | - Hitendu Dave
- 1 Department for Congenital Cardiovascular Surgery, 2 Divisions of Pediatric Cardiology and Children's Research Centre, 3 Department for Anesthesiology, 4 Department of Intensive Care and Neonatology, University Children's Hospital, Zurich, Switzerland
| | - Anna Cavigelli-Brunner
- 1 Department for Congenital Cardiovascular Surgery, 2 Divisions of Pediatric Cardiology and Children's Research Centre, 3 Department for Anesthesiology, 4 Department of Intensive Care and Neonatology, University Children's Hospital, Zurich, Switzerland
| | - Christian Balmer
- 1 Department for Congenital Cardiovascular Surgery, 2 Divisions of Pediatric Cardiology and Children's Research Centre, 3 Department for Anesthesiology, 4 Department of Intensive Care and Neonatology, University Children's Hospital, Zurich, Switzerland
| | - Oliver Kretschmar
- 1 Department for Congenital Cardiovascular Surgery, 2 Divisions of Pediatric Cardiology and Children's Research Centre, 3 Department for Anesthesiology, 4 Department of Intensive Care and Neonatology, University Children's Hospital, Zurich, Switzerland
| | - Christoph Bürki
- 1 Department for Congenital Cardiovascular Surgery, 2 Divisions of Pediatric Cardiology and Children's Research Centre, 3 Department for Anesthesiology, 4 Department of Intensive Care and Neonatology, University Children's Hospital, Zurich, Switzerland
| | - Dietrich Klauwer
- 1 Department for Congenital Cardiovascular Surgery, 2 Divisions of Pediatric Cardiology and Children's Research Centre, 3 Department for Anesthesiology, 4 Department of Intensive Care and Neonatology, University Children's Hospital, Zurich, Switzerland
| | - Michael Hübler
- 1 Department for Congenital Cardiovascular Surgery, 2 Divisions of Pediatric Cardiology and Children's Research Centre, 3 Department for Anesthesiology, 4 Department of Intensive Care and Neonatology, University Children's Hospital, Zurich, Switzerland
| |
Collapse
|
16
|
Sehgal S, Blake JM, Sommerfield J, Aggarwal S. Strain and strain rate imaging using speckle tracking in acute allograft rejection in children with heart transplantation. Pediatr Transplant 2015; 19:188-95. [PMID: 25532819 DOI: 10.1111/petr.12415] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2014] [Indexed: 12/01/2022]
Abstract
Acute allograft rejection is a major cause of morbidity and mortality following heart transplantation. There is no reliable noninvasive test to diagnose rejection. We aimed to investigate the accuracy of strain by speckle tracking echocardiography in the detection of acute rejection. We identified acute rejection episodes in patients followed at a single transplant center. Data were collected at baseline, during rejection and two follow-up points. Peak systolic radial and circumferential strain at the level of papillary muscles and peak systolic longitudinal strain from apical four-chamber view were analyzed offline. ANOVA was used for comparison between groups. p value ≤0.05 was considered significant. Fifteen rejection episodes were identified. There were no differences in the fractional shortening, LV posterior wall thickness, E/A, septal E/E', septal S', lateral E/E', lateral S', or MPI during rejection, compared to baseline. There was a significant increase in the LV mass during a rejection episode (47.5 vs. 34.4 g/ht(2.7) [p = 0.03]). The peak systolic radial strain (18.3 vs. 26.5; p = 0.03), longitudinal strain (-11.7 vs. -14.6; p = 0.05), and circumferential strain (-14.4 vs. -21.7; p = 0.05) declined significantly during rejection. In conclusion, peak systolic radial, longitudinal and circumferential strain decline and LV mass increases during an episode of rejection.
Collapse
Affiliation(s)
- Swati Sehgal
- Division of Cardiology, Children's Hospital of Michigan, Wayne State University, Detroit, MI, USA
| | | | | | | |
Collapse
|
17
|
Paediatric dilated cardiomyopathy: clinical profile and outcome. The experience of a tertiary centre for paediatric cardiology. Cardiol Young 2015; 25:333-7. [PMID: 24423967 DOI: 10.1017/s1047951113002369] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Dilated cardiomyopathy is the most common form of cardiomyopathy in the paediatric population and an important cause of heart transplantation in children. The clinical profile and course of dilated cardiomyopathy in children have been poorly characterised. A retrospective review of 61 patients (37 female; 24 male) diagnosed with dilated cardiomyopathy from January, 2005 to June, 2012 at a single institution was performed. The median age at diagnosis was 15 months. Heart failure was present in 83.6% of patients and 44.3% required intensive care. The most prevalent causes were idiopathic (47.5%), viral myocarditis (18.0%) and inherited metabolic diseases (11.5%). In viral myocarditis, Parvovirus B19 was the most common identified agent, in concurrence with the increasing incidence documented recently. Inherited metabolic diseases were responsible for 11.5% of dilated cardiomyopathy cases compared with the 4-6% described in the literature, which reinforces the importance of considering this aetiology in differential diagnosis of paediatric dilated cardiomyopathy. The overall mortality rate was 16.1% and five patients underwent heart transplantation. In our series, age at diagnosis and aetiology were the most important prognosis factors. We report no mortality in the five patients who underwent heart transplantation, after 2 years of follow-up.
Collapse
|
18
|
Tainio J, Qvist E, Miettinen J, Hölttä T, Pakarinen M, Jahnukainen T, Jalanko H. Blood pressure profiles 5 to 10 years after transplant in pediatric solid organ recipients. J Clin Hypertens (Greenwich) 2015; 17:154-61. [PMID: 25557075 DOI: 10.1111/jch.12465] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Revised: 10/31/2014] [Accepted: 11/04/2014] [Indexed: 01/20/2023]
Abstract
Arterial hypertension is a major risk factor for cardiovascular disease after solid organ transplantation, emphasizing the need for blood pressure (BP) monitoring. The authors studied 24-hour ambulatory BP monitoring (ABPM) parameters (index, load, dipping) and their predictive value with regard to hypertension as well as correlations with graft function and metabolic parameters such as obesity and dyslipidemias. The ABPM profiles of 111 renal, 29 heart, and 13 liver transplant recipients were retrospectively analyzed 5 to 10 years after transplant (median 5.1 years). The BP profiles among the different transplant groups were similar. The BP index and load were abnormal especially at nighttime and the nocturnal BP dipping was often blunted (in 49% to 83% of the patients). The BP variables were found to be equally valued when assessing hypertension. BP load of 50% instead of 25% seems to be a more adequate cutoff value. The BP variables correlated poorly with the metabolic parameters and kidney function. Antihypertensive medication did not notably change the ABPM profile in renal transplant recipients. Hypertension, including nocturnal hypertension, is present in children receiving solid organ transplant, underlining the importance of use of ABPM in the follow-up of these patients.
Collapse
Affiliation(s)
- Juuso Tainio
- Children's Hospital, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | | | | | | | | | | | | |
Collapse
|
19
|
Weber R, Kantor P, Chitayat D, Friedberg MK, Golding F, Mertens L, Nield LE, Ryan G, Seed M, Yoo SJ, Manlhiot C, Jaeggi E. Spectrum and outcome of primary cardiomyopathies diagnosed during fetal life. JACC-HEART FAILURE 2014; 2:403-11. [PMID: 25023818 DOI: 10.1016/j.jchf.2014.02.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 02/05/2014] [Accepted: 02/25/2014] [Indexed: 01/22/2023]
Abstract
OBJECTIVES The purpose of this study was to determine the phenotypic presentation, causes, and outcome of fetal cardiomyopathy (CM) and to identify early predictors of outcome. BACKGROUND Although prenatal diagnosis is possible, there is a paucity of information about fetal CM. METHODS This was a retrospective review of 61 consecutive fetal cases with a diagnosis of CM at a single center between 2000 and 2012. RESULTS Nonhypertrophic CM (NHCM) was diagnosed in 40 and hypertrophic CM (HCM) in 21 fetuses at 24.7 ± 5.7 gestational weeks. Etiologies included familial (13%), inflammatory (15%), and genetic-metabolic (28%) disorders, whereas 44% were idiopathic. The pregnancy was terminated in 13 of 61 cases (21%). Transplantation-free survival from diagnosis to 1 month and 1 year of life for actively managed patients was better in those with NHCM (n = 31; 58% and 58%, respectively) compared with those with HCM (n = 17; 35% and 18%, respectively; hazard ratio [HR]: 0.44; 95% confidence interval [CI]: 0.12 to 0.72; p = 0.007). Baseline echocardiographic variables associated with mortality in actively managed patients included ventricular septal thickness (HR: 1.21 per z-score increment; 95% CI: 1.07 to 1.36; p = 0.002), cardiothoracic area ratio (HR: 1.06 per percent increment; 95% CI: 1.02 to 1.10; p = 0.006), ≥3 abnormal diastolic Doppler flow indexes (HR: 1.44; 95% CI: 1.07 to 1.95; p = 0.02), gestational age at CM diagnosis (HR: 0.91 per week increment; 95% CI: 0.83 to 0.99; p = 0.03), and, for fetuses in sinus rhythm, a lower cardiovascular profile score (HR: 1.45 per point decrease; 95% CI: 1.16 to 1.79; p = 0.001). CONCLUSIONS Fetal CM originates from a broad spectrum of etiologies and is associated with substantial mortality. Early echocardiographic findings appear useful in predicting adverse perinatal outcomes.
Collapse
Affiliation(s)
- Roland Weber
- Fetal Cardiac Program, Labatt Family Heart Center, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Paul Kantor
- Heart Failure Program, Labatt Family Heart Center, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - David Chitayat
- Prenatal Diagnosis and Medical Genetics Programs, Mount Sinai Hospital; University of Toronto, Toronto, Ontario, Canada
| | - Mark K Friedberg
- Fetal Cardiac Program, Labatt Family Heart Center, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Fraser Golding
- Fetal Cardiac Program, Labatt Family Heart Center, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Luc Mertens
- Fetal Cardiac Program, Labatt Family Heart Center, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Lynne E Nield
- Fetal Cardiac Program, Labatt Family Heart Center, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Greg Ryan
- Fetal Medicine Unit, Mount Sinai Hospital; University of Toronto, Toronto, Ontario, Canada
| | - Mike Seed
- Fetal Cardiac Program, Labatt Family Heart Center, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Shi-Joon Yoo
- Fetal Cardiac Program, Labatt Family Heart Center, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Cedric Manlhiot
- Fetal Cardiac Program, Labatt Family Heart Center, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Edgar Jaeggi
- Fetal Cardiac Program, Labatt Family Heart Center, The Hospital for Sick Children, Toronto, Ontario, Canada.
| |
Collapse
|
20
|
Suryanarayana PG, Copeland H, Friedman M, Copeland JG. Cardiac transplantation in African Americans: a single-center experience. Clin Cardiol 2014; 37:331-6. [PMID: 24692148 DOI: 10.1002/clc.22275] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2013] [Revised: 02/18/2014] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND In view of limited data on the subject of graft and patient survival differences between African American (AA) and non-AA heart transplant recipients, we reviewed our experience. HYPOTHESIS There is a higher mortality among AA recipients compared with non-AA recipients after cardiac transplantation. METHODS The study included all AA patients who have received a heart transplant in our center since 1983. Stepwise Cox regression was used for covariates affecting the survival. The χ(2) test was employed to identify the effects of a mechanical assist device and pretransplant creatinine (Cr) on the outcomes in AA and non-AA patients. Kaplan-Meier curves were used to examine survival. RESULTS The average survival among AA recipients was 5.4 years, compared with 12 years for the non-AA recipients, with 1-, 5-, and 10-year survival rates of 80%, 55%, and 25%, respectively. This was found to be statistically inferior to the survival probabilities of 92%, 78%, and 58% for the non-AA group (P < 0.005). Based on stepwise Cox regression, the variables such as ethnicity (P < 0.05), pretransplant Cr (P < 0.05), presence of a mechanical assist device (P < 0.005), and United Network for Organ Sharing (UNOS) status at transplant (P < 0.05) independently predicted the outcomes. Kaplan-Meier analysis of pretransplant Cr level and survival showed that the AA group did significantly worse for all Cr classes. CONCLUSIONS There is a statistically significant difference in outcomes between AA and non-AA patients after cardiac transplantation. African American patients have decreased survival over a period of time. Pretransplant Cr, ethnicity, presence of a mechanical assist device, and UNOS status at transplantation are independent predictors of outcomes.
Collapse
|
21
|
Kwon DH, Jung S, Lee EJ, Lee JY, Moon S, Lee JW, Chung NG, Cho B, Kim HK. Incidence and risk factors for early-onset hypertension after allogeneic hematopoietic stem cell transplantation in children. Korean Circ J 2013; 43:804-10. [PMID: 24385991 PMCID: PMC3875696 DOI: 10.4070/kcj.2013.43.12.804] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2013] [Revised: 10/21/2013] [Accepted: 10/23/2013] [Indexed: 12/28/2022] Open
Abstract
Background and Objectives Survivors of pediatric hematopoietic stem cell transplantation (HSCT) are at risk for developing hypertension. The objectives of this study are to evaluate the prevalence and risk factors of early onset hypertension during the engraftment period after HSCT. Subjects and Methods This is a retrospective study of 157 consecutive patients (mean age at HSCT: 9.1±5.1 years) who underwent HSCT for acute myeloid leukemia (n=47), acute lymphoblastic leukemia (n=43), severe aplastic anemia (n=41), and other reasons (n=26). Blood pressure data were collected at five time points: 0, 7, 14, 21, and 28 days after HSCT. Hypertension was defined as having systolic and/or diastolic blood pressure ≥95th percentile according to age, gender, and height. To analyze the risk factors related to hypertension, data, including patients' demographic and transplant characteristics, were reviewed. Results Hypertension developed in 59 patients (38%), among whom 12 (7.6%) required long term therapy. Thirty-two (54%) patients had systolic and diastolic, 8 (14%) had only systolic, and 19 (32%) had only diastolic hypertension. Younger age, acute graft-versus-host disease, sinusoidal obstruction syndrome, treatment with antifungal agent, and greater increase in serum creatinine (Cr) levels were associated with hypertension. Multivariate analysis showed that younger age at HSCT and greater increase in serum Cr level were independent risk factors for hypertension. Conclusion Prevalence of hypertension during immediate post-HSCT period is high, especially in younger children. A greater increase in Cr after HSCT was significantly associated with hypertension. Further study is needed to elucidate long-term cardiovascular complications in pediatric HSCT survivors.
Collapse
Affiliation(s)
- Dae Hyun Kwon
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seungwon Jung
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Eun-Jung Lee
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae Young Lee
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sena Moon
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae Wook Lee
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Nack Gyun Chung
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Bin Cho
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hack Ki Kim
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| |
Collapse
|
22
|
Gilljam T, Higgins T, Bennhagen R, Wåhlander H. First two decades of paediatric heart transplantation in Sweden - outcome of listing and post-transplant results. Acta Paediatr 2011; 100:1442-7. [PMID: 21645110 DOI: 10.1111/j.1651-2227.2011.02377.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIMS To evaluate outcome in the first generation of children with end-stage heart disease to whom heart transplantation was available. METHODS Retrospective review of all 135 Swedish children <18 years old listed for heart transplantation 1989-2009, followed to December 31, 2009, including 74 (55%) with cardiomyopathy and 61 (45%) with congenital heart disease; 34 (25%) were infants (<1 year). Cumulative risk of requiring heart transplantation was 1:17,300 (11 patients who improved were omitted from outcome analysis). RESULTS Waiting-list mortality was 31% (44% in infants). Median waiting time in 82 transplanted patients was 57 days (0-585 days). Post-transplant follow-up time was median 5.9 years (0.03-20.1 years), and actuarial survival was 92% at 1 year, 82% at 5 years, 76% at 10 years and 58% at 15 years. Survival after listing was 64% at 1 year, 58% at 5 years, 52% at 10 years and 40% at 15 years. Post-transplant complications included rejections (34%), malignancies (12%), renal failure (8%), coronary artery vasculopathy (6%) and re-transplantation (5%). Among 64 survivors, 84% were free of complications affecting prognosis. CONCLUSION High waiting-list mortality and post-transplant attrition precluded 60% of this pioneer population from reaching adulthood. Functional status in survivors is generally good.
Collapse
Affiliation(s)
- Thomas Gilljam
- Pediatric Cardiology, Queen Silvia Children's Hospital, Sahlgrenska Academy, Gothenburg University, Sweden.
| | | | | | | |
Collapse
|
23
|
Abstract
The purpose of this article is to provide a brief but systematic overview of heart failure and cardiomyopathy in children and the anesthetic management of these patients. We will begin with disease definitions and descriptions of the disorders. Our review will include the epidemiology and etiology of the more prevalent underlying causes of heart failure, the principal pathophysiology of the specific cardiomyopathies, as well as the common therapies in use today in both inpatient and outpatient settings. Important implications for anesthetic management will be highlighted.
Collapse
Affiliation(s)
- David N Rosenthal
- Pediatric Cardiology, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, CA, USA
| | | |
Collapse
|
24
|
Singh TP, Almond CS, Gauvreau K. Improved survival in pediatric heart transplant recipients: have white, black and Hispanic children benefited equally? Am J Transplant 2011; 11:120-8. [PMID: 21199352 PMCID: PMC4248354 DOI: 10.1111/j.1600-6143.2010.03357.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We assessed whether the improvement in posttransplant survival in pediatric heart transplant (HT) recipients during the last two decades has benefited the major racial groups in the United States equally. We analyzed all children <18 years of age who underwent their first HT in the US during 1987-2008. We compared trends in graft loss (death or retransplant) in white, black and Hispanic children in five successive cohorts (1987-1992, 1993-1996, 1997-2000, 2001-2004, 2005-2008). The primary endpoint was early graft loss within 6 months posttransplant. Longer-term survival was assessed in recipients who survived the first 6 months. The improvement in early posttransplant survival was similar (hazard ratio [HR] for successive eras 0.80, 95% confidence interval [CI] 0.7, 0.9, p = 0.24 for black-era interaction, p = 0.22 for Hispanic-era interaction) in adjusted analysis. Longer-term survival was worse in black children (HR 2.2, CI 1.9, 2.5) and did not improve in any group with time (HR 1.0 for successive eras, CI 0.9, 1.1, p = 0.57; p = 0.19 for black-era interaction, p = 0.21 for Hispanic-era interaction). Thus, the improvement in early post-HT survival during the last two decades has benefited white, black and Hispanic children equally. Disparities in longer-term survival have not narrowed with time; the survival remains worse in black recipients.
Collapse
Affiliation(s)
- T. P. Singh
- Department of Cardiology, Children’s Hospital Boston, Boston, MA,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - C. S. Almond
- Department of Cardiology, Children’s Hospital Boston, Boston, MA,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - K. Gauvreau
- Department of Cardiology, Children’s Hospital Boston, Boston, MA,Department of Biostatistics, Harvard School of Public Health, Boston, MA
| |
Collapse
|
25
|
Lambert V, Capderou A, Le Bret E, Rücker-Martin C, Deroubaix E, Gouadon E, Raymond N, Stos B, Serraf A, Renaud JF. Right ventricular failure secondary to chronic overload in congenital heart disease: an experimental model for therapeutic innovation. J Thorac Cardiovasc Surg 2010; 139:1197-204, 1204.e1. [PMID: 20412956 DOI: 10.1016/j.jtcvs.2009.11.028] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2009] [Revised: 10/07/2009] [Accepted: 11/14/2009] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Mortality and morbidity related to right ventricular failure remain a problem for the long-term outcome of congenital heart diseases. Therapeutic innovation requires establishing an animal model reproducing right ventricular dysfunction secondary to chronic pressure-volume overload. METHODS Right ventricular tract enlargement by transvalvular patch and pulmonary artery banding were created in 2-month-old piglets (n = 6) to mimic repaired tetralogy of Fallot. Age-matched piglets were used as controls (n = 5). Right ventricular function was evaluated at baseline and 3 and 4 months of follow-up by hemodynamic parameters and electrocardiography. Right ventricular tissue remodeling was characterized using cellular electrophysiologic and histologic analyses. RESULTS Four months after surgery, right ventricular peak pressure increased to 75% of systemic pressure and pulmonary regurgitation significantly progressed, end-systolic and end-diastolic volumes significantly increased, and efficient ejection fraction significantly decreased compared with controls. At 3 months, the slope of the end-systolic pressure-volume relationship was significantly elevated compared with baseline and controls; a significant rightward shift of the slope, returning to the baseline value, was observed at 4 months, whereas stroke work progressed at each step and was significantly higher than in controls. Four months after surgery, QRS duration was significantly prolonged as action potential duration. Significant fibrosis and myocyte hypertrophy without myolysis and inflammation were observed in the operated group at 4 months. CONCLUSION Various aspects of early right ventricular remodeling were analyzed in this model. This model reproduced evolving right ventricular alterations secondary to chronic volumetric and barometric overload, as observed in repaired tetralogy of Fallot with usual sequelae, and can be used for therapeutic innovation.
Collapse
Affiliation(s)
- Virginie Lambert
- Département de Recherche Médicale, CNRS UMR 8162, Centre Chirurgical Marie Lannelongue, Le Plessis Robinson, France.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Breinholt JP, Moulik M, Dreyer WJ, Denfield SW, Kim JJ, Jefferies JL, Rossano JW, Gates CM, Clunie SK, Bowles KR, Kearney DL, Bowles NE, Towbin JA. Viral epidemiologic shift in inflammatory heart disease: the increasing involvement of parvovirus B19 in the myocardium of pediatric cardiac transplant patients. J Heart Lung Transplant 2010; 29:739-46. [PMID: 20456978 DOI: 10.1016/j.healun.2010.03.003] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2009] [Revised: 02/24/2010] [Accepted: 03/03/2010] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Detection of viral genome in rejecting cardiac transplant patients has been reported, with coxsackievirus and adenovirus causing premature graft failure. Recently, parvovirus B19 (PVB19) genome in myocardial samples has been increasingly reported, but its role in cardiac pathology and effect on transplant graft survival are unknown. The objectives of this study were to determine if changes in the viruses identified in the myocardium represent an epidemiologic shift in viral myocardial disease and whether PVB19 adversely affects transplant graft survival. METHODS From September 2002 to December 2005, nested polymerase chain reaction was used to evaluate endomyocardial biopsy specimens for 99 children (aged 3 weeks-18 years) with heart transplants for the presence of viral genome. Cellular rejection was assessed by histology of specimens. Transplant coronary artery disease (TCAD) was diagnosed by coronary angiography or histopathology. RESULTS Specimens from 700 biopsies were evaluated from 99 patients; 121 specimens had viral genome, with 100 (82.6%) positive for PVB19, 24 for Epstein-Barr virus (EBV; 7 positive for PVB19 and EBV), 3 for CMV, and 1 for adenovirus. Presence of PVB19 genome did not correlate with rejection score, nor did a higher viral copy number. Early development of advanced TCAD (p < 0.001) occurred in 20 children with persistent PVB19 infection (> 6 months). CONCLUSIONS PVB19 is currently the predominant virus detected in heart transplant surveillance biopsy specimens, possibly representing an epidemiologic shift. Cellular rejection does not correlate with the presence or quantity of PVB19 genome in the myocardium, but children with chronic PVB19 infection have increased risk for earlier TCAD, supporting the hypothesis that PVB19 negatively affects graft survival.
Collapse
Affiliation(s)
- John P Breinholt
- Division of Pediatric Cardiology, Indiana University School of Medicine, Indianapolis, IN, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Gazit AZ, Huddleston CB, Checchia PA, Fehr J, Pezzella AT. Care of the pediatric cardiac surgery patient--part 2. Curr Probl Surg 2010; 47:261-376. [PMID: 20207257 DOI: 10.1067/j.cpsurg.2009.12.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Avihu Z Gazit
- Pediatric Critical Care Medicine and Cardiology, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri, USA
| | | | | | | | | |
Collapse
|
28
|
Era Effect on Post-transplant Survival Adjusted for Baseline Risk Factors in Pediatric Heart Transplant Recipients. J Heart Lung Transplant 2009; 28:1285-91. [DOI: 10.1016/j.healun.2009.05.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2009] [Revised: 03/26/2009] [Accepted: 05/01/2009] [Indexed: 11/22/2022] Open
|
29
|
Kaufman BD, Chuai S, Dobbels F, Shaddy RE. Wasting or obesity at time of transplant does not predict pediatric heart transplant outcomes: analysis of ISHLT pediatric heart transplant registry. J Heart Lung Transplant 2009; 28:1273-8. [PMID: 19783177 DOI: 10.1016/j.healun.2009.07.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2009] [Revised: 07/24/2009] [Accepted: 07/27/2009] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Body mass index (BMI) both before and after heart transplant (HT) is used to risk stratify in adult HT. Single-center studies identify BMI as a potential predictor of outcome after HT in children; large-scale analyses in pediatric HT have not been performed. METHODS The ISHLT pediatric heart transplant registry was queried for HT recipients >2 years old between 1996 and 2006 with data for BMI percentile (BMI%ile) at HT. Survival and morbidity rates post-HT were compared between BMI%ile cohorts defined as: wasted, <5th BMI%ile; normal, 5th to 95th BMI%ile; and obese, >95th BMI%ile at HT. RESULTS Data from 2,333 pediatric HT patients were available for analysis. Incidence of abnormal BMI%ile at HT was: wasted = 23% and obese = 8%. Wasting and obesity were similar in patients with congenital or cardiomyopathic diagnoses. Wasted or obese patients at HT did not differ from patients with normal BMI in survival on Kaplan-Meier or multivariate analyses. There were no significant differences in pre-, peri- or post-operative adverse events between patients with wasting or obesity and those with normal BMI%ile at HT. CONCLUSIONS In contrast to adults, abnormal body mass at time of transplant was not associated with decreased survival in pediatric HT recipients. Potential pediatric transplant candidates should not be excluded based on the perception that wasting or obesity will increase the risk of adverse outcomes.
Collapse
Affiliation(s)
- Beth D Kaufman
- Pediatric Heart Transplant Program, Department of Pediatrics, School of Medicine, University of Pennsylvania, Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104-4399, USA.
| | | | | | | |
Collapse
|
30
|
Ohta H, Fukushima N, Ozono K. Pediatric post-transplant lymphoproliferative disorder after cardiac transplantation. Int J Hematol 2009; 90:127-136. [DOI: 10.1007/s12185-009-0399-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2009] [Revised: 07/19/2009] [Accepted: 07/23/2009] [Indexed: 11/28/2022]
|
31
|
Pollock-BarZiv SM, Allain-Rooney T, Manlhiot C, Babu A, Nalli N, McCrindle BW, Dipchand AI. Continuous infusion of thymoglobulin for induction therapy in pediatric heart transplant recipients; experience and outcomes with a novel strategy for administration. Pediatr Transplant 2009; 13:585-9. [PMID: 18992051 DOI: 10.1111/j.1399-3046.2008.01035.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Minimal data exist on the perioperative use of TG for induction in pediatric HTx recipients. We report our experience using continuous infusion of TG on (i) perioperative adverse events, (ii) rejection, (iii) CAV, and (iv) PTLD. TG was infused via peripheral intravenous intra- and perioperatively as a continuous infusion (24 h/day). Starting dose was 1.5 mg/kg/day titrated to achieve target lymphocyte count of 0.1-0.3 x 10(9)/L. Fifty-five patients received TG; mean age at HTx was 4.4 yr (1 day-17.8 yr). The mean duration of TG was three and a half days (2-7 days). Median platelet count during TG infusion was 95 x 10(9)/L (28-228). Five patients had TG stopped for low platelets (at 4-6 days post-HTx) - all started maintenance immunosuppression. There was no perioperative mortality due to infection. Mean follow-up of 46 survivors was 2.3 yr (0.6-5.8 yr). Fifty-one percent had > or = ISHLT 2R rejection at a median time of 33 days post-HTx (7 days-2 yr). One patient developed PTLD 1.4 yr post-HTx; three patients developed mild-moderate CAV. TG as a continuous infusion appears to have a good safety profile. Though mild thrombocytopenia was prevalent, there was no bleeding attributable solely to TG. Whether early depletion of T-cell function will translate into long-term benefits remains to be determined.
Collapse
Affiliation(s)
- Stacey M Pollock-BarZiv
- The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | | | | | | | | | | | | |
Collapse
|
32
|
Uutela A, Qvist E, Holmberg C, Pihko H, Jalanko H. Headache in children and adolescents after organ transplantation. Pediatr Transplant 2009; 13:565-70. [PMID: 18466199 DOI: 10.1111/j.1399-3046.2008.00973.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The prevalence and characteristics of headache were studied in a national cohort of 177 pediatric patients with kidney, liver, and heart transplants. All patients received triple drug immunosuppression with CsA, Aza, and MP. Data on headaches were collected by sending two questionnaires and reviewing the medical records. Statements on headache were found in the medical records of 46% of the patients. According to a questionnaire, two thirds had experienced headaches sometime after transplantation, and 40% had present headaches. The episodes had significantly affected the quality of life in a third of the patients, and resulted in neurological examination in 15%. Most of the subjects (61%) described typical episode as mild or moderate, and 39% as severe or very severe. The usual episodes lasted <4 h in 73% of the patients and >4 h in 27%. The headache could be classified as migraine, probable migraine or headache without specific features in 33%, 31%, and 36%, respectively. Most patients (82%) had used pain-killers, mainly acetaminophen and ibuprofen. Headache episodes may significantly impair the quality of life in children and adolescents after organ transplantation.
Collapse
Affiliation(s)
- Aki Uutela
- Department of Pediatric Nephrology, Hospital for Children and Adolescents, University of Helsinki, Helsinki, Finland
| | | | | | | | | |
Collapse
|
33
|
Dionigi B, Razzouk AJ, Hasaniya NW, Chinnock RE, Bailey LL. Late outcomes of pediatric heart transplantation are independent of pre-transplant diagnosis and prior cardiac surgical intervention. J Heart Lung Transplant 2009; 27:1090-5. [PMID: 18926399 DOI: 10.1016/j.healun.2008.07.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2008] [Revised: 06/23/2008] [Accepted: 07/01/2008] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND An increasing number of children are being referred for cardiac transplantation after (1) failing conventional corrective or palliative surgical reconstruction, (2) after stabilization with mechanical circulatory support devices, and (3) when primary graft failure or advanced cardiac allograft vasculopathy are established. METHODS The records of 417 infants and children (age range, 0-18 years) who underwent cardiac transplantation from November 1985 through December 2005 at Loma Linda University Children's Hospital were retrospectively reviewed. The pre-transplantation diagnosis was used to divide patients into 3 groups: primary cardiomyopathy (CM), 103; hypoplastic left heart syndrome (HLHS), 154; and other complex congenital heart disease (CCHD), 160. These groups were compared and analyzed for differences in early and late morbidity and mortality. RESULTS Operative mortality was significantly lower in the CM group compared with the HLHS (p < 0.02;) and CCHD groups (p < 0.01). Long-term actuarial recipient survival, however, was similar for all groups. The 15-year actuarial survival was 59% for the CM Group, 57% for the HLHS Group, and 50% for the CCHD Group. Actuarial survival after retransplantation is not statistically different from that with primary cardiac transplantation. CONCLUSION Although peri-operative survival was lower in infants and children with HLHS and CCHD compared with those with CM, long-term survival has been the same for all groups. Late survival after retransplantation was not statistically different than among those with primary cardiac transplantation.
Collapse
|
34
|
Bharat W, Manlhiot C, McCrindle BW, Pollock-BarZiv S, Dipchand AI. The profile of renal function over time in a cohort of pediatric heart transplant recipients. Pediatr Transplant 2009; 13:111-8. [PMID: 18093086 DOI: 10.1111/j.1399-3046.2007.00848.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
To assess the burden over time of renal dysfunction in pediatric heart transplant patients using an objective measure on an annual basis for serial comparison. GFR was measured at regular interval by nuclear medicine scintigraphy. Results were analyzed in relation to age, time post-transplantation, gender, and average calcineurin-inhibitor dose for the first two months post-transplantation. Results were compared with cGFR using the Schwartz equation. A total of 91 patients (56 males) transplanted between 1990 and 2004 underwent 373 GFR measurements. Median age at transplantation was 3.3 yr (birth - 17.8). Median first GFR at 0.7 yr (0.1-4.1) post-transplant was normal (94 mL/kg/1.73 m(2)). Freedom from at least mild renal insufficiency was 84% and 33% at one and five years post-transplant. Females had better renal function early post-transplant (GFR 105 mL/min/1.73 m(2)) but an increased probability of an abnormal GFR over time. Higher calcineurin inhibitor dose in the first two months post-transplantation was associated with an increasing probability of an abnormal GFR over time. The cGFR overestimated the measured GFR by 33 +/- 26 mL/kg/1.73 m(2). Renal insufficiency is an important morbidity after pediatric transplantation with the majority of patients experiencing at least mild renal dysfunction. Calculated GFR significantly underestimates the burden of renal insufficiency in this patient population.
Collapse
Affiliation(s)
- Winston Bharat
- Labatt Family Heart Centre, Hospital for Sick Children and Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | | | | | | | | |
Collapse
|
35
|
Ameduri RK, Canter CE. Current practice in immunosuppression in pediatric cardiac transplantation. PROGRESS IN PEDIATRIC CARDIOLOGY 2009. [DOI: 10.1016/j.ppedcard.2008.10.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
36
|
Dipchand AI, Bharat W, Manlhiot C, Safi M, Lobach NE, McCrindle BW. A prospective study of dobutamine stress echocardiography for the assessment of cardiac allograft vasculopathy in pediatric heart transplant recipients. Pediatr Transplant 2008; 12:570-6. [PMID: 18363614 DOI: 10.1111/j.1399-3046.2007.00861.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Transplant CAV is the leading cause of graft loss beyond one yr post-heart transplant. Diagnosis can be challenging and the previous "gold standard," coronary ANG, tends to underestimate disease. The purpose of this study was to relate DSE to ANG for the diagnosis of CAV. Prospective annual DSE at a single centre on all heart transplant patients (1999-2006) were compared with results from routine coronary angiograms. Progression of CAV over time as determined by DSE and ANG and associated factors were sought through logistic regression models adjusted for repeated measures. There were 102 heart transplant patients (54 males) transplanted between 1989 and 2006. Median age at transplant was 17 months (0-16.6 yr). The initial DSE was at a median of 10-months post-transplantation. There was a high correlation between an abnormal DSE and an abnormality on ANG (p = 0.002). There was an increased probability of an abnormal DSE with increasing grade of CAV as assessed by ANG (p < 0.001). Factors associated with an abnormal DSE included older age at transplant (p = 0.04), higher grade of rejection (p = 0.002), higher total cholesterol (p = 0.04), higher LDL (p < 0.05), and older age at the time of DSE (p = 0.002). DSE result was not related to HDL, triglyceride or homocysteine levels, or to steroid or statin use. The probability of an abnormal DSE result increases with increasing angiographic grade of CAV, and thus DSE may be used for initial screening for CAV with ANG reserved for confirmation and grading. Patients transplanted at an older age and those with a greater history of rejection were at higher risk of a positive DSE and may require increased surveillance for CAV.
Collapse
Affiliation(s)
- Anne I Dipchand
- Labatt Family Heart Centre, Hospital for Sick Children and Department of Pediatrics, University of Toronto, Toronto, ON, Canada.
| | | | | | | | | | | |
Collapse
|
37
|
Paige SL, Murry CE, Boucek RJ. Potential strategies for myocardial regeneration in pediatric patients. ACTA ACUST UNITED AC 2008. [DOI: 10.2217/17455111.2.4.503] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Owing to the heart’s limited ability for self-repair, heart failure is a leading cause of death among all patient populations. Thus, a cell-based regenerative strategy for cardiac repair would be highly attractive. A variety of cell sources have been identified as candidates for myocardial repair, including skeletal myoblasts, various bone marrow stem cells, resident cardiac progenitors and embryonic stem cells. However, nearly all studies geared towards myocardial regeneration, both in animal models and in clinical trials, have focused on adult ischemic disease with regional muscle injury. Pediatric patients suffer from more diverse forms of heart disease, including congenital and acquired cardiomyopathies with global muscle dysfunction, as well as disorders of cardiac development, for example, left ventricular hypoplasia, atrial or ventricular septal defects. In this article, a broad range of cell-based therapies are discussed, emphasizing the rapidly evolving science surrounding these strategies and the outstanding questions before application to pediatric patients. It is probable that many of the cell types and delivery strategies capable of repairing adult myocardial diseases will require additional investigations to take advantage of the unique opportunities and challenges of pediatric patients.
Collapse
Affiliation(s)
- Sharon L Paige
- University of Washington, Department of Pathology & Center for Cardiovascular Biology, Institute for Stem Cell & Regenerative Medicine, 815 Mercer Street, Seattle, WA 98109, USA
| | - Charles E Murry
- University of Washington, Department of Pathology & Department of Bioengineering & Center for Cardiovascular Biology, Institute for Stem Cell & Regenerative Medicine, 815 Mercer Street, Seattle, WA 98109, USA
| | - Robert J Boucek
- University of Washington, Department of Pediatrics, Children’s Hospital Research Center, 1900 9th Ave, Seattle, WA 98101, USA
| |
Collapse
|
38
|
Too fat or too thin? Body habitus assessment in children listed for heart transplant and impact on outcome. J Heart Lung Transplant 2008; 27:508-13. [PMID: 18442716 DOI: 10.1016/j.healun.2008.01.026] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2007] [Revised: 12/28/2007] [Accepted: 01/24/2008] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Body habitus assessment (BHA), be it wasted or obese, is a useful marker of nutritional status and overall medical condition. Wasting and obesity pre-heart transplant adversely affects outcomes in adults. The utility of BHA as a prognostic factor in children post-transplant is unknown. METHODS Weight and height at listing and standard growth charts were used to determine the ideal body weight (%IBW) and percentiles for body mass index for age (BMI%) and weight-for-length (W:L%). Wasting was defined as <90%IBW and/or <or=5th percentile for BMI% or W:L%. Obesity was defined as >120%IBW and/or >or=95th percentile BMI% or W:L%. Outcomes of cohorts based on these criteria were compared. RESULTS From June 1990 to December 2006, 180 children, aged 5.81 +/- 6 years, were listed for transplant. Wasting occurred in 66 (37%) and obesity in 22 (12%) children, without differences between diagnoses of cardiomyopathy or congenital heart disease. %IBW was a prognostic factor for survival post-transplant on multivariate analysis: obese patients had a hazard ratio (HR) of 3.82 (95% confidence interval [CI] 1.81 to 8.06) compared with normal BHA (p < 0.001). Wasting had a survival advantage compared with normal BHA (HR 0.51, 95% CI 0.27 to 0.94, p = 0.032). There were no significant differences between cohorts in incidence of infections, first-year rejections or graft vasculopathy. CONCLUSIONS Abnormal BHA at listing was a prognostic factor for survival post-transplant. Obese children had increased mortality, but wasting did not adversely affect post-transplant survival in our population. Body habitus assessment may risk-stratify children at listing, potentially providing a complex target for intervention.
Collapse
|
39
|
Abstract
To discuss the indications for and outcomes of cardiac retransplantation in childhood. The major challenge of pediatric heart transplantation is graft failure. The major causes of graft failure include coronary allograft vasculopathy and chronic rejection. Retransplantation may be considered in children or young adults who develop graft failure following pediatric heart transplantation. Retransplantation now accounts for 7% of all pediatric transplants. Recent studies have demonstrated that cardiac retransplantation has a poorer outcome than primary heart transplantation. However, the interval from primary transplant to retransplantation appears to impact significantly the success of retransplantation. When children undergo retransplantation for early graft failure, the survival is quite poor and the appropriateness of this strategy is questionable. However, children who undergo retransplantation many years after primary transplantation have outcomes that are similar to primary transplantation. The decision to pursue retransplantation depends on the severity of graft failure and recent data suggest that identification of mild graft dysfunction or coronary allograft vasculopathy does not imply impending graft failure. Novel therapies to extend the life of the primary graft and to stratify those at risk of severe graft dysfunction will improve the allocation of scarce organs for pediatric patients who might be candidates for cardiac retransplantation. Retransplantation can extend the lives of children who develop graft failure after primary transplantation. However, not all patients who develop graft dysfunction should necessarily be listed for retransplantation.
Collapse
Affiliation(s)
- William T Mahle
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA 30322-1062, USA.
| |
Collapse
|
40
|
Kulikowska A, Boslaugh SE, Huddleston CB, Gandhi SK, Gumbiner C, Canter CE. Infectious, malignant, and autoimmune complications in pediatric heart transplant recipients. J Pediatr 2008; 152:671-7. [PMID: 18410772 DOI: 10.1016/j.jpeds.2007.10.018] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2007] [Revised: 08/13/2007] [Accepted: 10/13/2007] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To review clinical courses of pediatric heart transplant survivors after 5 years from transplantation for infections, lymphoproliferative, and autoimmune diseases. STUDY DESIGN A total of 71 patients were examined in 2 groups, infant recipients (underwent transplant <1 year of age, n = 38) and older recipients (underwent transplant >1 year, n = 33). All patients received comparable immunosuppression. Calculated occurrence rates were reported as means per 10 years of follow-up with SEs. Differences were examined by using Poisson regression. RESULTS Infant recipients had significantly higher (P < .001) occurrence rates of severe (mean, 2.04 +/- 0.5) and chronic infections (mean, 4.58 +/- 0.67) compared with older recipients (means, 0.37 +/- 0.19 and 1.87 +/- 0.70, respectively). Types of infections were similar to those in the general population with extremely rare opportunistic infections; however, they were more severe and resistant to treatment. Autoimmune disorders occurred at a frequency comparable with lymphoproliferative diseases and were observed in 7 of 38 infants (18%). Most common were autoimmune cytopenias. CONCLUSIONS Infant heart transplant recipients who survive in the long term have higher occurrence rates of infections compared with older recipients. Autoimmune disorders are a previously unrecognized morbidity in pediatric heart transplantation.
Collapse
|
41
|
Roche SL, Kaufmann J, Dipchand AI, Kantor PF. Hypertension After Pediatric Heart Transplantation is Primarily Associated With Immunosuppressive Regimen. J Heart Lung Transplant 2008; 27:501-7. [DOI: 10.1016/j.healun.2008.01.018] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2007] [Revised: 12/18/2007] [Accepted: 01/13/2008] [Indexed: 11/16/2022] Open
|
42
|
Rossano JW, Denfield SW, Kim JJ, Price JF, Jefferies JL, Decker JA, Smith EO, Clunie SK, Towbin JA, Dreyer WJ. B-type natriuretic peptide is a sensitive screening test for acute rejection in pediatric heart transplant patients. J Heart Lung Transplant 2008; 27:649-54. [PMID: 18503965 DOI: 10.1016/j.healun.2008.03.008] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2008] [Revised: 02/25/2008] [Accepted: 03/12/2008] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND The utility of B-type natriuretic peptide (BNP) for detecting acute rejection (AR) is unclear. The purpose of our study was to evaluate BNP as a screening test for AR in pediatric heart transplant patients. METHODS All endomyocardial biopsies (EMBs) with concurrent BNP levels from February 2004 through March 2007 at the study institution were reviewed and the association between BNP levels and acute rejection was assessed. RESULTS Eighty-six patients underwent a total of 560 EMBs. The median age at EMB was 10.5 years (interquartile range [IQR] 3.7 to 15.4 years). There were 59 episodes of AR, 32 (54%) occurring at <1 year post-transplant. BNP levels were higher in patients with AR, median 387 pg/ml (IQR 125 to 931 pg/ml), compared with those without AR, median 66 pg/ml (IQR 37 to 148 pg/ml) (p < 0.001). The receiver operating characteristic (ROC) curve for BNP demonstrated an area under the curve (AUC) of 0.82 (95% confidence interval [CI] 0.76 to 0.88) (p < 0.001). A BNP level of 100 pg/ml corresponded to a sensitivity of 0.85 (95% CI 0.73 to 0.92) and a negative predictive value (NPV) of 0.97 (95% CI 0.95 to 0.99) for detecting AR. The ROC curve for patients at >1 year post-transplant demonstrated an AUC of 0.86 (95% CI 0.80 to 0.93) (p < 0.001), and a BNP level of 100 pg/ml corresponded to a sensitivity of 0.96 (95% CI 0.79 to 0.99) and NPV of 0.994 (95% CI 0.962 to 0.999) for detecting AR. CONCLUSIONS BNP levels have a high sensitivity and NPV for evaluating AR in pediatric heart transplant patients. In patients >1 year post-transplant, a BNP level of <100 pg/ml correlates with a <1% chance of AR and may obviate the need for EMB in some cases.
Collapse
Affiliation(s)
- Joseph W Rossano
- Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas 77030, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Tjang YS, Stenlund H, Tenderich G, Hornik L, Bairaktaris A, Körfer R. Risk Factor Analysis in Pediatric Heart Transplantation. J Heart Lung Transplant 2008; 27:408-15. [DOI: 10.1016/j.healun.2008.01.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2007] [Revised: 12/10/2007] [Accepted: 01/02/2008] [Indexed: 11/25/2022] Open
|
44
|
Abstract
OBJECTIVE To identify factors that influence parents' decisions when asked to donate a deceased child's organs. DESIGN Cross-sectional design with data collection via structured telephone interviews. SETTING One organ procurement organization in the Southeastern United States. PARTICIPANTS Seventy-four parents (49 donors, 25 nondonors) of donor-eligible deceased children who were previously approached by coordinators from one organ procurement organization in the southeastern United States. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Multivariate analyses showed that organ donation was more likely when the parent was a registered organ donor (odds ratio [OR] = 1.4, confidence interval [CI] = 1.1, 2.7), the parent had favorable organ donation beliefs (OR = 5.5, CI = 2.7, 12.3), the parent was exposed to organ donation information before the child's death (OR = 2.6, CI = 1.7, 10.3), a member of the child's healthcare team first mentioned organ donation (OR = 1.4, CI = 1.2, 3.7), the requestor was perceived as sensitive to the family's needs (OR = 0.4, CI = 0.2, 0.7), the family had sufficient time to discuss donation (OR = 5.2, CI = 1.4, 11.6), and family members were in agreement about donation (OR = 2.8, CI = 1.3, 5.2). CONCLUSIONS This study identifies several modifiable variables that influence the donation decision-making process for parents. Strategies to facilitate targeted organ donation education and higher consent rates are discussed.
Collapse
|
45
|
Behera SK, Trang J, Feeley BT, Levi DS, Alejos JC, Drant S. The use of Doppler tissue imaging to predict cellular and antibody-mediated rejection in pediatric heart transplant recipients. Pediatr Transplant 2008; 12:207-14. [PMID: 18307670 DOI: 10.1111/j.1399-3046.2007.00812.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
DTI indices have been associated with cellular rejection in adult heart transplant recipients, but their predictive value in pediatric recipients is unknown. The purpose of this study was to evaluate DTI measures in the detection of cellular and AMR in pediatric heart transplant recipients. One hundred and forty-eight pediatric heart transplant recipients who had 267 cardiac catheterization procedures with EMB, echocardiogram with DTI, and BNP level performed on the same day were included in the study. For the mitral and tricuspid valves, the ratios (E/E') between the early diastolic inflow velocity by pulsed Doppler (E, m/s) and the early diastolic annular velocity by DTI (E', m/s) were obtained and compared between subjects with and without rejection. Of the 148 recipients, 30 subjects had a total of 37 episodes of rejection: 10 cellular (>or=1B), 17 AMR, and 10 biopsy-negative clinical rejection. Mitral and tricuspid valve E/E' ratios were significantly higher in rejectors than in non-rejectors (5.5 +/- 1.3 vs. 4.4 +/- 1.4, p < 0.001 and 4.9 +/- 2.1 vs. 4.1 +/- 1.5, p < 0.01, respectively). By multivariate linear regression, mitral valve E/E' was an independent predictor of rejection. Mitral and tricuspid valve E/E' <5.0 had 93% and 89% NPV, respectively, for rejection. Mitral and tricuspid valve E/E' ratios <5.0 may be useful non-invasive screening measures to exclude rejection in pediatric heart transplant recipients.
Collapse
Affiliation(s)
- Sarina K Behera
- Department of Pediatrics, University of California, Los Angeles, CA, USA.
| | | | | | | | | | | |
Collapse
|
46
|
Cohen O, De La Zerda D, Beygui RE, Hekmat D, Laks H. Ethnicity as a predictor of graft longevity and recipient mortality in heart transplantation. Transplant Proc 2008; 39:3297-302. [PMID: 18089375 DOI: 10.1016/j.transproceed.2007.06.086] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2007] [Revised: 05/10/2007] [Accepted: 06/21/2007] [Indexed: 11/28/2022]
Abstract
BACKGROUND There is a dearth of data about the effect of donor and recipient ethnicity on survival and rejection rate after clinical heart transplantation, although the subject had been partly studied before. We compared the mortality and rejection rate among different ethnic groups at our institution. METHODS In retrospect, 525 consecutive donors provided cardiac allografts to adult and pediatric patients undergoing orthotropic heart transplantation at a single, urban US medical center between 2000 and 2005. Donors and recipients were categorized according to ethnicity: African American, Asian, Caucasian, Hispanic, and Others (Indian, Mediterranean/Arabic, Afghans). Donor and recipient ethnicity-as an independent factor and the interaction between them-were examined as a risk factor for mortality and rejection after heart transplantation. Mean follow-up period was 3.2+/-1.9 years (range, 0.1 to 6.6). All recipients received triple immunosuppression consisting of a calcineurin inhibitor, an antiproliferative agent, and steroids. No patients received induction immunotherapy. The end points of the study were early and late mortality, rejection rate, and rejection-free survival time. RESULTS The overall mortality was 17.3% (91 patients). Recipient mortality rate according to donor race was: African American, 23.1%; Asian, 11.1%; Caucasian, 18.7%; and Hispanic, 14.6%. No statistical significance was found, although the mortality differences presented. Recipient mortality with regard to recipients ethnicity was: African American, 22.2%; Asian, 6.3%; Caucasian, 18%; Hispanic, 18.9%; and others 40% (P=.048). Donor-recipient race match was not found as a risk factor influencing mortality as the matched group mortality was 17.5% comparing with the mismatched group mortality of 17.8% (P=.874). The overall rejection rate was 3.8% (20 rejection events). Rejection rate according donor race was: African American, 7.7%; Asian, 10.7%; Caucasian, 4%; and Hispanic, 1.3% (P=.027). Rejection rate with respect to recipients ethnicity was: African American, 0; Asian, 3.2%; Caucasian, 4.4%; Hispanic, 2.7%; and others, 20% with no statistical significance (P=.236). Donor recipient race match was not found as a risk factor influencing rejection rate (P=.58). CONCLUSIONS Recipients' ethnicity was found as a significant risk factor for mortality. Rejection rate were found higher among the African American donors and significantly lower in the Hispanic donors. Significantly lower mortality rate was found among Asian recipients. Donor-recipient race match did not influence the mortality or rejection rate.
Collapse
Affiliation(s)
- O Cohen
- Department of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California 90095, USA.
| | | | | | | | | |
Collapse
|
47
|
Renal Transplantation After Previous Pediatric Heart Transplantation. J Heart Lung Transplant 2008; 27:217-21. [DOI: 10.1016/j.healun.2007.10.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2007] [Revised: 10/24/2007] [Accepted: 10/25/2007] [Indexed: 11/22/2022] Open
|
48
|
Pollock-Barziv SM, McCrindle BW, West LJ, Dipchand AI. Waiting before birth: outcomes after fetal listing for heart transplantation. Am J Transplant 2008; 8:412-8. [PMID: 18093275 DOI: 10.1111/j.1600-6143.2007.02047.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Following fetal diagnosis of a profound heart defect, transplantation (HTx) is an alternative to pregnancy termination or neonatal surgical palliation. Retrospective review of the cardiac and transplant databases of fetal listings for HTx between 1990 and July 2006 was undertaken to describe outcomes after listing. We identified 26 fetal listings (of 269 total listings). Diagnoses included congenital heart disease (n = 24) and cardiomyopathy (n = 2). Seven patients were delisted after birth: in five cases parents opted for surgical palliation, two clinically improved. One patient died wait-listed (stillborn). Time wait-listed as a fetus ranged from 1-41 days (median 19 days). Eighteen patients underwent HTx (median weight 2.8 kg, range 2.1-10.9 kg); median days wait-listed after birth was 22 (4 h-123 days). Two fetuses were surgically delivered at 36 weeks gestation when a donor organ became available; 11 were transplanted as neonates (<30 days). The median age at HTx was 1 month (4 h-2.6 months). Fetal listing for HTx increases the potential window of opportunity for a donor organ to become available; patients had low wait-list mortality and a fair intermediate-term outcome. Well-defined criteria for eligibility for fetal listing and priority allocation to infants over fetuses seem rational approaches for centers that offer fetal listing.
Collapse
Affiliation(s)
- S M Pollock-Barziv
- The Hospital for Sick Children, Labatt Family Heart Centre, Heart Transplant Program, The University of Toronto, Toronto, Ontario, Canada
| | | | | | | |
Collapse
|
49
|
|
50
|
Tjang YS, Stenlund H, Tenderich G, Hornik L, Körfer R. Pediatric Heart Transplantation: Current Clinical Review. J Card Surg 2008; 23:87-91. [DOI: 10.1111/j.1540-8191.2007.00494.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|