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Greenberg JW, Guzman-Gomez A, Kulshrestha K, Dani A, Lehenbauer DG, Chin C, Zafar F, Morales DLS. Contemporary Outcomes of Heart Transplantation in Children with Heterotaxy Syndrome: Sub-Optimal Pre-Transplant Optimization Translates into Early Post-Transplant Mortality. Pediatr Cardiol 2023:10.1007/s00246-023-03122-z. [PMID: 36811659 DOI: 10.1007/s00246-023-03122-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/02/2023] [Indexed: 02/24/2023]
Abstract
Patients with heterotaxy syndrome and congenital heart disease (CHD) experience inferior cardiac surgical outcomes. Heart transplantation outcomes are understudied, however, particularly compared to non-CHD patients. Data from UNOS and PHIS were used to identify 4803 children (< 18 years) undergoing first-time heart transplant between 2003 and 2022 with diagnoses of heterotaxy (n = 278), other-CHD (n = 2236), and non-CHD cardiomyopathy (n = 2289). Heterotaxy patients were older (median 5 yr) and heavier (median 17 kg) at transplant than other-CHD (median 2 yr and 12 kg), and younger and lighter than cardiomyopathy (median 7 yr and 24 kg) (all p < 0.001). UNOS status 1A/1 at listing was not different between groups (65-67%; p = 0.683). At transplant, heterotaxy and other-CHD patients had similar rates of renal dysfunction (12 and 17%), inotropes (10% and 11%), and ventilator-dependence (19 and 18%). Compared to cardiomyopathy, heterotaxy patients had comparable renal dysfunction (9%, p = 0.058) and inotropes (46%, p = 0.097) but more hepatic dysfunction (17%, p < 0.001) and ventilator-dependence (12%, p = 0.003). Rates of ventricular assist device (VAD) were: heterotaxy-10%, other-CHD-11% (p = 0.839 vs. heterotaxy), cardiomyopathy-37% (p < 0.001 vs. heterotaxy). The 1-year incidence of acute rejection post-transplant was comparable between heterotaxy and others (p > 0.05). While overall post-transplant survival was significantly worse for heterotaxy than others (p < 0.05 vs. both), conditional 1-year survival was comparable (p > 0.3 vs. both). Children with heterotaxy syndrome experience inferior post-heart transplant survival, although early mortality appears to influence this trend, with 1-year survivors having equivalent outcomes. Given similar pre-transplant clinical status to others, heterotaxy patients are potentially under risk-stratified. Increased VAD utilization and pre-transplant end-organ function optimization may portend improved outcomes.
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Affiliation(s)
- Jason W Greenberg
- Cincinnati Children's Hospital Medical Center, The Heart Institute, University of Cincinnati School of Medicine, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.
| | - Amalia Guzman-Gomez
- Cincinnati Children's Hospital Medical Center, The Heart Institute, University of Cincinnati School of Medicine, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - Kevin Kulshrestha
- Cincinnati Children's Hospital Medical Center, The Heart Institute, University of Cincinnati School of Medicine, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - Alia Dani
- Cincinnati Children's Hospital Medical Center, The Heart Institute, University of Cincinnati School of Medicine, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - David G Lehenbauer
- Cincinnati Children's Hospital Medical Center, The Heart Institute, University of Cincinnati School of Medicine, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - Clifford Chin
- Cincinnati Children's Hospital Medical Center, The Heart Institute, University of Cincinnati School of Medicine, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - Farhan Zafar
- Cincinnati Children's Hospital Medical Center, The Heart Institute, University of Cincinnati School of Medicine, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - David L S Morales
- Cincinnati Children's Hospital Medical Center, The Heart Institute, University of Cincinnati School of Medicine, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
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Altin F, Alsoufi B, Kanter K, Deshpande SR. Systemic Venous Reconstructions During Pediatric Heart Transplantation. World J Pediatr Congenit Heart Surg 2021; 12:583-588. [PMID: 34597211 DOI: 10.1177/21501351211020699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Congenital heart disease continues to be an important indication for pediatric heart transplantation (HT) and is often complicated by systemic venous anomalies. The need for reconstruction, surgical technique used, as well as the outcomes of these have limited documentation. METHODS Descriptive, retrospective study of patients transplanted at Emory University between 2006 and 2017. We reviewed surgical data, follow-up, and interventions for patients necessitating venous reconstruction during transplantation. RESULTS A total of 179 transplants were performed during the time period of which 74 (41%) required systemic venous reconstruction. Mean age at transplant was 6.3 (±6.16) years, and 74.3% of these patients carried a diagnosis of single ventricle; 51 (68.9%) of 74 patients required pulmonary artery reconstruction at the time of HT. Forty patients required superior vena caval reconstruction, while 22 patients required inferior vena caval reconstruction due to prior palliation or anomaly. Venous anomalies along with other anatomic features necessitated biatrial transplantation in four patients. Posttransplant evaluation revealed systemic venous stenosis in 14 (18.9%) of 74 patients. Eight (10.8%) patients required 12 interventions for the systemic veins. Patients with bilateral Glenn anastomosis prior to transplant were at high risk for the development of stenosis and needing interventions. Systemic venous complications were uncommon in those with native systemic veins without Glenn or Fontan procedure. CONCLUSION Systemic venous reconstruction needs are high in pediatric HT. Posttransplant stenosis and the need for interventions are relatively common. Current techniques for systemic venous reconstruction for complex congenital heart disease patients may deserve further review to optimize these outcomes.
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Affiliation(s)
- Firat Altin
- Department of Pediatric Cardiac Surgery, Dr Siyami Ersek Thoracic and Cardiovascular Training and Research Hospital, Istanbul, Turkey
| | - Bahaaldin Alsoufi
- Department of Cardiothoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, KY, USA
| | - Kirk Kanter
- Cardiothoracic Surgery, Emory University, Children's Healthcare of Atlanta, GA, USA
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De Luca R, Davis PJ, Lin HY, Gionfra F, Percario ZA, Affabris E, Pedersen JZ, Marchese C, Trivedi P, Anastasiadou E, Negro R, Incerpi S. Thyroid Hormones Interaction With Immune Response, Inflammation and Non-thyroidal Illness Syndrome. Front Cell Dev Biol 2021; 8:614030. [PMID: 33553149 PMCID: PMC7859329 DOI: 10.3389/fcell.2020.614030] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/14/2020] [Indexed: 12/14/2022] Open
Abstract
The interdependence between thyroid hormones (THs), namely, thyroxine and triiodothyronine, and immune system is nowadays well-recognized, although not yet fully explored. Synthesis, conversion to a bioactive form, and release of THs in the circulation are events tightly supervised by the hypothalamic-pituitary-thyroid (HPT) axis. Newly synthesized THs induce leukocyte proliferation, migration, release of cytokines, and antibody production, triggering an immune response against either sterile or microbial insults. However, chronic patho-physiological alterations of the immune system, such as infection and inflammation, affect HPT axis and, as a direct consequence, THs mechanism of action. Herein, we revise the bidirectional crosstalk between THs and immune cells, required for the proper immune system feedback response among diverse circumstances. Available circulating THs do traffic in two distinct ways depending on the metabolic condition. Mechanistically, internalized THs form a stable complex with their specific receptors, which, upon direct or indirect binding to DNA, triggers a genomic response by activating transcriptional factors, such as those belonging to the Wnt/β-catenin pathway. Alternatively, THs engage integrin αvβ3 receptor on cell membrane and trigger a non-genomic response, which can also signal to the nucleus. In addition, we highlight THs-dependent inflammasome complex modulation and describe new crucial pathways involved in microRNA regulation by THs, in physiological and patho-physiological conditions, which modify the HPT axis and THs performances. Finally, we focus on the non-thyroidal illness syndrome in which the HPT axis is altered and, in turn, affects circulating levels of active THs as reported in viral infections, particularly in immunocompromised patients infected with human immunodeficiency virus.
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Affiliation(s)
- Roberto De Luca
- Department of Neurology, Center for Life Science, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Paul J. Davis
- Pharmaceutical Research Institute, Albany College of Pharmacy and Health Sciences, Albany, NY, United States
- Albany Medical College, Albany, NY, United States
| | - Hung-Yun Lin
- Pharmaceutical Research Institute, Albany College of Pharmacy and Health Sciences, Albany, NY, United States
- Taipei Cancer Center, Taipei Medical University, Taipei, Taiwan
- Graduate Institute of Cancer Biology and Drug Discovery, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
- Traditional Herbal Medicine Research Center of Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan
- TMU Research Center of Cancer Translational Medicine, Taipei Medical University, Taipei, Taiwan
| | - Fabio Gionfra
- Department of Sciences, University “Roma Tre,” Rome, Italy
| | | | | | - Jens Z. Pedersen
- Department of Biology, University of Rome Tor Vergata, Rome, Italy
| | - Cinzia Marchese
- Department of Experimental Medicine, University “La Sapienza,” Rome, Italy
| | - Pankaj Trivedi
- Department of Experimental Medicine, University “La Sapienza,” Rome, Italy
| | - Eleni Anastasiadou
- Department of Experimental Medicine, University “La Sapienza,” Rome, Italy
| | - Roberto Negro
- National Institute of Gastroenterology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) “S. de Bellis” Research Hospital, Castellana Grotte, Italy
| | - Sandra Incerpi
- Department of Sciences, University “Roma Tre,” Rome, Italy
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Duong SQ, Godown J, Soslow JH, Thurm C, Hall M, Sainathan S, Morell VO, Dodd DA, Feingold B. Increased mortality, morbidities, and costs after heart transplantation in heterotaxy syndrome and other complex situs arrangements. J Thorac Cardiovasc Surg 2019; 157:730-740.e11. [PMID: 30669235 PMCID: PMC6865268 DOI: 10.1016/j.jtcvs.2018.11.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 10/22/2018] [Accepted: 11/04/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Identify pediatric heart transplant (HT) recipients with heterotaxy and other complex arrangements of cardiac situs (heterotaxy/situs anomaly) and compare mortality, morbidities, length of stay (LOS), and costs to recipients with congenital heart disease without heterotaxy/situs anomaly. METHODS Using linked registry data (2001-2016), we identified 186 HT recipients with heterotaxy/situs anomaly and 1254 with congenital heart disease without heterotaxy/situs anomaly. We compared post-HT outcomes in univariable and multivariable time-to-event analyses. LOS and cost from HT to discharge were compared using Wilcoxon rank-sum tests. Sensitivity analyses were performed using stricter heterotaxy/situs anomaly group inclusion criteria and through propensity matching. RESULTS HT recipients with heterotaxy/situs anomaly were older (median age, 5.1 vs 1.6 years; P < .001) and more often black, Asian, Hispanic, or "other" nonwhite (54% vs 32%; P < .001). Heterotaxy/situs anomaly was independently associated with increased mortality (hazard ratio, 1.58; 95% confidence interval, 1.19-2.09; P = .002), even among 6-month survivors (hazard ratio, 1.86; 95% confidence interval, 1.09-3.16; P = .021). Heterotaxy/situs anomaly recipients more commonly required dialysis (odds ratio, 2.58; 95% confidence interval, 1.51-4.42; P = .001) and cardiac reoperation (odds ratio, 1.91; 95% confidence interval, 1.17-3.11; P = .010) before discharge. They had longer ischemic times (19.2 additional minutes [range, 10.9-27.5 minutes]; P < .001), post-HT intensive care unit LOS (16 vs 13 days; P = .012), and hospital LOS (26 vs 23 days; P = .005). Post-HT hospitalization costs were also greater ($447,604 vs $379,357; P = .001). CONCLUSIONS Heterotaxy and other complex arrangements of cardiac situs are associated with increased mortality, postoperative complications, LOS, and costs after HT. Although increased surgical complexity can account for many of these differences, inferior late survival is not well explained and deserves further study.
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Affiliation(s)
- Son Q Duong
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Justin Godown
- Division of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tenn
| | - Jonathan H Soslow
- Division of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tenn
| | - Cary Thurm
- Children's Hospital Association, Lenexa, Kan
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kan
| | - Sandeep Sainathan
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Victor O Morell
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Debra A Dodd
- Division of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tenn
| | - Brian Feingold
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pa; Department of Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pa.
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Kenny LA, DeRita F, Nassar M, Dark J, Coats L, Hasan A. Transplantation in the single ventricle population. Ann Cardiothorac Surg 2018; 7:152-159. [PMID: 29492393 DOI: 10.21037/acs.2018.01.16] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The single ventricle patient population comprises the most complex cohort presenting to the cardiac transplant team, in terms of demographics, anatomic substrate, and unique physiology. It is also the most rapidly growing diagnostic group presenting for heart transplantation. In this manuscript, we aim to describe the changing landscape of transplantation in single ventricle conditions through reflection on our own institution's practice and experience, alongside contemporary literature review. Single ventricle patients are heterogeneous in terms of age, anatomic diagnosis and physiology according to surgical stage of repair. Progress in surgical palliative strategies has impacted upon the present composition of the population, with growing numbers of hypoplastic left heart syndrome patients and those with late physiology failure following Fontan completion. Multiple prior surgeries, immunological sensitivity and multi-organ involvement impart high peri-operative risk but can be mitigated in part by careful pre-operative planning by a dedicated multi-disciplinary team addressing issues such as planning of concurrent reconstructive surgery, minimizing the post-operative effect of collaterals, timely harvesting, oversizing of donor organs to minimize graft failure, and strategies to address anticipated post-operative elevation in pulmonary vascular resistance. Determining optimal timing for transplant in these patients remains unclear, but understanding the risk of alternative surgical options can help guide decision making with regards to listing.
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Affiliation(s)
- Louise A Kenny
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Fabrizio DeRita
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Mohamed Nassar
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, UK.,Cardiothoracic Surgery Department, Alexandria University, Alexandria, Egypt
| | - John Dark
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, UK.,Institute of Cellular Medicine, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Louise Coats
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, UK.,Cardiovascular Research Centre, Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Asif Hasan
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, UK
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6
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Teele SA, Jacobs JP, Border WL, Chanani NK. Heterotaxy Syndrome: Proceedings From the 10th International PCICS Meeting. World J Pediatr Congenit Heart Surg 2016; 6:616-29. [PMID: 26467876 DOI: 10.1177/2150135115604470] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
A session dedicated to heterotaxy syndrome was included in the program of the Tenth International Conference of the Pediatric Cardiac Intensive Care Society in Miami, Florida in December 2014. An invited panel of experts reviewed the anatomic considerations, surgical considerations, noncardiac issues, and long-term outcomes in this challenging group of patients. The presentations, summarized in this article, reflect the current approach to this complex multiorgan syndrome and highlight future areas of clinical interest and research.
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Affiliation(s)
- Sarah A Teele
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jeffrey P Jacobs
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA Johns Hopkins All Children's Heart Institute, All Children's Hospital, Saint Petersburg and Tampa, FL, USA
| | - William L Border
- Sibley Heart Center Cardiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Nikhil K Chanani
- Sibley Heart Center Cardiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
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7
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Ross HJ, Law Y, Book WM, Broberg CS, Burchill L, Cecchin F, Chen JM, Delgado D, Dimopoulos K, Everitt MD, Gatzoulis M, Harris L, Hsu DT, Kuvin JT, Martin CM, Murphy AM, Singh G, Spray TL, Stout KK. Transplantation and Mechanical Circulatory Support in Congenital Heart Disease. Circulation 2016; 133:802-20. [DOI: 10.1161/cir.0000000000000353] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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8
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Stout KK, Broberg CS, Book WM, Cecchin F, Chen JM, Dimopoulos K, Everitt MD, Gatzoulis M, Harris L, Hsu DT, Kuvin JT, Law Y, Martin CM, Murphy AM, Ross HJ, Singh G, Spray TL. Chronic Heart Failure in Congenital Heart Disease. Circulation 2016; 133:770-801. [DOI: 10.1161/cir.0000000000000352] [Citation(s) in RCA: 219] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Abstract
CHD is frequently associated with a genetic syndrome. These syndromes often present specific cardiovascular and non-cardiovascular co-morbidities that confer significant peri-operative risks affecting multiple organ systems. Although surgical outcomes have improved over time, these co-morbidities continue to contribute substantially to poor peri-operative mortality and morbidity outcomes. Peri-operative morbidity may have long-standing ramifications on neurodevelopment and overall health. Recognising the cardiovascular and non-cardiovascular risks associated with specific syndromic diagnoses will facilitate expectant management, early detection of clinical problems, and improved outcomes--for example, the development of syndrome-based protocols for peri-operative evaluation and prophylactic actions may improve outcomes for the more frequently encountered syndromes such as 22q11 deletion syndrome.
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10
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Bang JH, Oh YN, Yoo JS, Kim JJ, Park CS, Park JJ. Heart Transplantation in a Patient with Left Isomerism. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2015; 48:277-80. [PMID: 26290840 PMCID: PMC4541059 DOI: 10.5090/kjtcs.2015.48.4.277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 10/23/2014] [Accepted: 10/27/2014] [Indexed: 11/16/2022]
Abstract
We report the case of a 37-year-old man who suffered from biventricular failure due to left isomerism, inferior vena cava interruption with azygos vein continuation, bilateral superior vena cava, double outlet of right ventricle, complete atrioventricular septal defect, pulmonary stenosis, and isolated dextrocardia. Heart transplantation in patients with systemic venous anomalies often requires the correction and reconstruction of the upper & lower venous drainage. We present a case of heart transplantation in a patient with left isomerism, highlighting technical modifications to the procedure, including the unifocalization of the caval veins and reconstruction with patch augmentation.
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Affiliation(s)
- Ji Hyun Bang
- Division of Pediatric Cardiac Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - You Na Oh
- Division of Pediatric Cardiac Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Jae Suk Yoo
- Division of Pediatric Cardiac Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Jae-Joong Kim
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine
| | - Chun Soo Park
- Division of Pediatric Cardiac Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Jeong-Jun Park
- Division of Pediatric Cardiac Surgery, Asan Medical Center, University of Ulsan College of Medicine
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Abstract
Pediatric heart transplantation (HTx) remains an important treatment option in the care of children with end-stage heart disease, whether it is secondary to cardiomyopathy or congenital heart disease (CHD). As surgical outcomes for CHD have improved, the indications for pediatric HTx have had to be dynamic, not only for children with CHD but also for the growing population of adults with CHD. As the field of pediatric HTx has evolved, the outcomes for children undergoing HTx have improved. This is undoubtedly due to the continued research efforts of both single-center studies, as well as research collaboratives such as the International Society for Heart and Lung Transplantation (ISHLT) and the Pediatric Heart Transplant Study (PHTS) group. Research collaboratives are increasingly important in pediatric HTx as single center studies for a limited patient population may not elicit strong enough evidence for practice evolution. Similarly, complications that limit the long term graft survival may occur in a minority of patients thus pooled experience is essential. This review focuses on the indications and outcomes for pediatric HTx, with a special emphasis on studies generated by these research collaboratives.
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Affiliation(s)
- Philip T Thrush
- 1 The Heart Center, Nationwide Children's Hospital, 2 Department of Pediatrics, The Ohio State University, Columbus, OH, USA
| | - Timothy M Hoffman
- 1 The Heart Center, Nationwide Children's Hospital, 2 Department of Pediatrics, The Ohio State University, Columbus, OH, USA
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12
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Thrush PT, Hoffman TM. Pediatric heart transplantation-indications and outcomes in the current era. J Thorac Dis 2014; 6:1080-96. [PMID: 25132975 DOI: 10.3978/j.issn.2072-1439.2014.06.16] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 06/04/2014] [Indexed: 12/20/2022]
Abstract
Pediatric heart transplantation (HTx) remains an important treatment option in the care of children with end-stage heart disease, whether it is secondary to cardiomyopathy or congenital heart disease (CHD). As surgical outcomes for CHD have improved, the indications for pediatric HTx have had to be dynamic, not only for children with CHD but also for the growing population of adults with CHD. As the field of pediatric HTx has evolved, the outcomes for children undergoing HTx have improved. This is undoubtedly due to the continued research efforts of both single-center studies, as well as research collaboratives such as the International Society for Heart and Lung Transplantation (ISHLT) and the Pediatric Heart Transplant Study (PHTS) group. Research collaboratives are increasingly important in pediatric HTx as single center studies for a limited patient population may not elicit strong enough evidence for practice evolution. Similarly, complications that limit the long term graft survival may occur in a minority of patients thus pooled experience is essential. This review focuses on the indications and outcomes for pediatric HTx, with a special emphasis on studies generated by these research collaboratives.
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Affiliation(s)
- Philip T Thrush
- 1 The Heart Center, Nationwide Children's Hospital, 2 Department of Pediatrics, The Ohio State University, Columbus, OH, USA
| | - Timothy M Hoffman
- 1 The Heart Center, Nationwide Children's Hospital, 2 Department of Pediatrics, The Ohio State University, Columbus, OH, USA
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13
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Vallabhajosyula P, Komlo C, Wallen TJ, Olthoff K, Pochettino A. Combined heart-liver transplant in a situs-ambiguous patient with failed Fontan physiology. J Thorac Cardiovasc Surg 2013; 145:e39-e41. [DOI: 10.1016/j.jtcvs.2012.12.066] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 12/18/2012] [Indexed: 11/28/2022]
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14
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Heart transplantation in congenital heart disease: in whom to consider and when? J Transplant 2013; 2013:376027. [PMID: 23577237 PMCID: PMC3614026 DOI: 10.1155/2013/376027] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2012] [Accepted: 12/19/2012] [Indexed: 11/18/2022] Open
Abstract
Due to impressive improvements in surgical repair options, even patients with complex congenital heart disease (CHD) may survive into adulthood and have a high risk of end-stage heart failure. Thus, the number of patients with CHD needing heart transplantation (HTx) has been increasing in the last decades. This paper summarizes the changing etiology of causes of death in heart failure in CHD. The main reasons, contraindications, and risks of heart transplantation in CHD are discussed and underlined with three case vignettes. Compared to HTx in acquired heart disease, HTx in CHD has an increased risk of perioperative death and rejection. However, outcome of HTx for complex CHD has improved over the past 20 years. Additionally, mechanical support options might decrease the waiting list mortality in the future. The number of patients needing heart-lung transplantation (especially for Eisenmenger's syndrome) has decreased in the last years. Lung transplantation with intracardiac repair of a cardiac defect is another possibility especially for patients with interatrial shunts. Overall, HTx will remain an important treatment option for CHD in the near future.
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15
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Mora BN, Huddleston CB. Heart transplantation in biventricular congenital heart disease: indications, techniques, and outcomes. Curr Cardiol Rev 2013; 7:92-101. [PMID: 22548032 PMCID: PMC3197094 DOI: 10.2174/157340311797484196] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2011] [Revised: 06/13/2011] [Accepted: 06/13/2011] [Indexed: 11/22/2022] Open
Abstract
Heart transplantation is an accepted therapeutic modality for end-stage congenital heart disease for both biventricular and univentricular anomalies. Many transplant centers have pushed the limits of transplantation to include patients with high pulmonary vascular resistance, high panel reactive antibodies, positive cross-matches, and ABO-incompatibility. Excellent results have been possible, particularly with the development of improved diagnostic and therapeutic algorithms to prevent and treat rejection, infection, and post-transplant lymphoproliferative disease. Late graft failure and chronic rejection remain vexing problems. The vast majority of patients with biventricular congenital heart disease have undergone prior cardiac surgical procedures. Indications for transplantation in this subgroup are primarily progressive refractory heart failure following prior cardiac surgical reconstructive procedures. Contraindications to transplantation mimic those for other forms of end-stage heart disease. A determination of pulmonary vascular resistance is important in listing patients with biventricular congenital heart disease for heart transplantation. Modifications in the implant technique are necessary and vary depending on underlying recipient anatomy. Risk factors for perioperative outcomes in patients with biventricular congenital heart disease include the need for reoperation, the degree of anatomic reconstruction necessary during the implant procedure, and the degree of antibody sensitization, in addition to a number of other recipient and donor factors. Postoperative outcomes and survival are very good but remain inferior to those with cardiomyopathy in most series. In conclusion, patients with end-stage biventricular congenital heart disease represent a complex group of patients for heart transplantation, and require careful evaluation and management to ensure optimal outcomes.
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Affiliation(s)
- Bassem N Mora
- Section of Pediatric Cardiothoracic Surgery, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri 63110, United States of America
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16
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Guleserian KJ, Schechtman KB, Zheng J, Edens RE, Jacobs JP, Mahle WT, Emerson SL, Naftel DC, Kirklin JK, Blume ED, Canter CE. Outcomes after listing for primary transplantation for infants with unoperated-on non-hypoplastic left heart syndrome congenital heart disease: A multi-institutional study. J Heart Lung Transplant 2011; 30:1023-32. [DOI: 10.1016/j.healun.2011.03.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Revised: 03/14/2011] [Accepted: 03/29/2011] [Indexed: 10/18/2022] Open
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17
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Combined Heart and Liver Transplantation in a Patient With Situs Ambiguous. Ann Thorac Surg 2011; 91:600-1. [DOI: 10.1016/j.athoracsur.2010.07.078] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2010] [Revised: 06/11/2010] [Accepted: 07/21/2010] [Indexed: 11/18/2022]
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18
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Williams GD, Feng A. Heterotaxy Syndrome: Implications for Anesthesia Management. J Cardiothorac Vasc Anesth 2010; 24:834-44. [DOI: 10.1053/j.jvca.2010.02.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2009] [Indexed: 11/11/2022]
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19
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Sebastian VA, Guleserian KJ, Leonard SR, Forbess JM. Heart Transplantation Techniques after Hybrid Single-Ventricle Palliation. J Card Surg 2010; 25:596-600. [DOI: 10.1111/j.1540-8191.2010.01055.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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20
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21
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Beiras-Fernandez A, Daebritz SH, Kaczmarek I, Kozlik-Feldmann R, Tiete AR, Reichart B. Challenging venous reconstruction and heart transplantation in a patient with viscero-atrial situs inversus and complex congenital heart disease with Fontan circulation. J Heart Lung Transplant 2007; 26:290-2. [PMID: 17346633 DOI: 10.1016/j.healun.2006.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2006] [Revised: 11/23/2006] [Accepted: 12/12/2006] [Indexed: 10/23/2022] Open
Abstract
Heart transplantation represents a valuable therapeutic option for patients with congenital heart disease and end-stage heart failure. We report the case of a 15-year-old patient with situs inversus and additional complex congenital malformations of the heart who underwent several previous palliative operations. Orthotopic cardiac transplantation with several technical modifications was performed successfully. At 18 months post-operatively the patient is free from rejection and doing well in New York Heart Association (NYHA) Class I status.
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Affiliation(s)
- A Beiras-Fernandez
- Department of Cardiac Surgery, Grosshadern University Hospital, University of Munich, Munich, Germany.
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22
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Canter CE, Shaddy RE, Bernstein D, Hsu DT, Chrisant MRK, Kirklin JK, Kanter KR, Higgins RSD, Blume ED, Rosenthal DN, Boucek MM, Uzark KC, Friedman AH, Friedman AH, Young JK. Indications for Heart Transplantation in Pediatric Heart Disease. Circulation 2007; 115:658-76. [PMID: 17261651 DOI: 10.1161/circulationaha.106.180449] [Citation(s) in RCA: 173] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Since the initial utilization of heart transplantation as therapy for end-stage pediatric heart disease, improvements have occurred in outcomes with heart transplantation and surgical therapies for congenital heart disease along with the application of medical therapies to pediatric heart failure that have improved outcomes in adults. These events justify a reevaluation of the indications for heart transplantation in congenital heart disease and other causes of pediatric heart failure.
Methods and Results—
A working group was commissioned to review accumulated experience with pediatric heart transplantation and its use in patients with unrepaired and/or previously repaired or palliated congenital heart disease (children and adults), in patients with pediatric cardiomyopathies, and in pediatric patients with prior heart transplantation. Evidence-based guidelines for the indications for heart transplantation or retransplantation for these conditions were developed.
Conclusions—
This evaluation has led to the development and refinement of indications for heart transplantation for patients with congenital heart disease and pediatric cardiomyopathies in addition to indications for pediatric heart retransplantation.
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23
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Tchervenkov CI, Jacobs ML, Del Duca D. Surgery for the functionally univentricular heart in patients with visceral heterotaxy. Cardiol Young 2006; 16 Suppl 1:72-9. [PMID: 16401367 DOI: 10.1017/s1047951105002362] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The heterotaxy syndromes are characterized by a high incidence of cardiac anomalies of extreme heterogeneity. Due to this, the surgical management is varied and challenging. Although a minority of patients can undergo biventricular repair, the complexity of the cardiac defects, and the high incidence of ventricular hypoplasia, mandate a surgical approach in the majority of patients depending on the creation of a functionally univentricular heart. Traditionally, the functionally univentricular approach was associated with a high mortality. More recently, the results have been improving as a result of better understanding of these malformations, and logical improvements in surgical technique. In this review, we will make brief comments on the nomenclature and classification of the heterotaxy syndromes, and the range of cardiac anomalies, before concentrating on the surgical treatment for those patients having functionally univentricular hearts in the setting of heterotaxy. More specifically, we will review initial palliation in early life, creation of the cavopulmonary anastomoses, including the Kawashima procedure and the Fontan circulation, and the role of transplantation.
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Affiliation(s)
- Christo I Tchervenkov
- Division of Cardiovascular Surgery, Montreal Children's Hospital of the McGill University Health Center, McGill University, Montréal, Québec, Canada.
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24
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Raisky O, Tamisier D, Vouhé PR. Orthotopic heart transplantation for congenital heart defects: anomalies of the systemic venous return. Multimed Man Cardiothorac Surg 2006; 2006:mmcts.2005.001578. [PMID: 24413330 DOI: 10.1510/mmcts.2005.001578] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Anomalies of the systemic venous return are frequently associated with other congenital heart defects. Some anomalies do not complicate really orthotopic heart transplantation (such as azygos continuation of the inferior vena cava). Other anomalies raise more difficulties; the most frequent one is persistent left superior vena cava draining into either the coronary sinus or the left atrium. Sometimes, the left superior vena cava can be ligated without untoward effect. In most cases, the left superior vena cava must be anastomosed to the right atrial compartment, preferably using extracardiac procedures. Most problems can be solved by harvesting extra lengths of donor superior vena cava and innominate vein. In rare patients, associated anomalies of the pulmonary venous return may require additional partitioning of the atria. The early risk of heart transplantation is probably not increased by the presence of such anomalies.
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Affiliation(s)
- Olivier Raisky
- Department of Pediatric Cardiac Surgery, Groupe Hospitalier Necker - Enfants Malades, 149 rue de Sèvres, 75015 Paris, France
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25
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Freedom RM, Jaeggi ET, Lim JS, Anderson RH. Hearts with isomerism of the right atrial appendages - one of the worst forms of disease in 2005. Cardiol Young 2005; 15:554-67. [PMID: 16297247 DOI: 10.1017/s1047951105001708] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/03/2005] [Indexed: 11/07/2022]
Affiliation(s)
- Robert M Freedom
- The Division of Cardiology, the Hospital for Sick Children, Toronto, Canada
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26
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Lim JSL, McCrindle BW, Smallhorn JF, Golding F, Caldarone CA, Taketazu M, Jaeggi ET. Clinical Features, Management, and Outcome of Children With Fetal and Postnatal Diagnoses of Isomerism Syndromes. Circulation 2005; 112:2454-61. [PMID: 16216960 DOI: 10.1161/circulationaha.105.552364] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Isomerism is associated with a complex spectrum of anomalies. There is paucity of data on prenatally detected cases.
Methods and Results—
Between January 1990 and February 2004, 83 of 166 cases (50%) had a prenatal diagnosis of left isomerism (LAI; 52 of 97) or right isomerism (RAI; 31 of 69) at our institution. The spectrum of anomalies, management, and outcomes was compared for fetal and postnatal diagnoses of LAI and RAI. RAI more often than LAI was associated with AV septal defect (90% versus 56%;
P
<0.0001), pulmonary outflow obstruction (91% versus 37%;
P
<0.0001), total anomalous pulmonary venous drainage (73% versus 13%;
P
<0.0001), and abnormal VA connections (68% versus 33%;
P
<0.0001), whereas inferior vena cava interruption (3% versus 93%;
P
<0.0001), complete AV block (0% versus 13%;
P
=0.004), aortic obstruction (6% versus 33%;
P
<0.0001), and extracardiac defects (5% versus 25%;
P
=0.006) were less common. The spectrum of lesions was comparable for fetal and postnatal cases, except for AV block (fetal, 25%; postnatal, 0%;
P
=0.0002) and AV septal defect (fetal, 67%; postnatal, 42%;
P
=0.023) in LAI. Fetal demise was due mainly to pregnancy termination (LAI, 42%; RAI, 45%). Survival of actively managed children with LAI was significantly better than for those with RAI (
P
<0.0001) but did not differ with regard to fetal versus postnatal diagnosis. Most LAI cases required no intervention or underwent successful biventricular cardiac surgery (65%), unlike RAI cases (13%;
P
<0.0001).
Conclusions—
Prenatal diagnosis did not affect overall survival despite facilitated care. The prognosis of RAI was worse compared with LAI because of more complex associated cardiac defects and the inability to perform successful surgical procedures.
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Affiliation(s)
- Joyce S L Lim
- Division of Cardiology, Hospital for Sick Children, University of Toronto, Toronto, Canada
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27
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Kon AA. Discussing Nonsurgical Care With Parents of Newborns With Hypoplastic Left Heart Syndrome. ACTA ACUST UNITED AC 2005. [DOI: 10.1053/j.nainr.2005.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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28
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Chen JM, Davies RR, Mital SR, Mercando ML, Addonizio LJ, Pinney SP, Hsu DT, Lamour JM, Quaegebeur JM, Mosca RS. Trends and Outcomes in Transplantation for Complex Congenital Heart Disease: 1984 to 2004. Ann Thorac Surg 2004; 78:1352-61; discussion 1352-61. [PMID: 15464499 DOI: 10.1016/j.athoracsur.2004.04.012] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/01/2004] [Indexed: 11/24/2022]
Abstract
BACKGROUND Cardiac transplantation for patients with complex congenital heart disease poses several anatomic and physiologic challenges for the transplant surgeon. We undertook the current single center study to evaluate surgical outcomes and lessons learned through a nearly twenty year experience with cardiac transplantation for complex congenital heart disease. METHODS A retrospective review was performed to evaluate all patients undergoing cardiac transplantation from January 1, 1984 through January 1, 2004. Donor and recipient demographic and intraoperative and postoperative variables were acquired and correlated with perioperative (30-day) and late mortality in both univariate and multivariate analyses, and with Kaplan-Meier survival estimates. RESULTS One hundred and six patients underwent transplantation for complex congenital heart disease and were followed for a median of 56 months. Thirty-seven (34.9%) patients died. Male gender and later year of transplantation were protective, and neonatal age and pulmonary artery reconstruction detrimental in multivariable modeling of overall mortality. Transplantation to a physiologic or anatomic single lung did not impact on survival. Patients in the study cohort had comparable survival estimates when compared with all those in the entire cohort without complex congenital heart disease. When comparing patients by era of transplantation, both cohorts demonstrated improved survival with later transplantation. CONCLUSIONS Outcomes with transplantation for complex congenital heart disease have improved annually over the past twenty years. Transplantation to an anatomic or physiologic single lung did not impair overall survival. Pulmonary artery reconstruction imparted an increase in mortality both short and long term, a finding which merits further investigation.
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Affiliation(s)
- Jonathan M Chen
- Division of Pediatric Cardiac Surgery, Columbia University College of Physicians and Surgeons, New York, New York, USA.
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29
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Michielon G, Parisi F, Squitieri C, Carotti A, Gagliardi G, Pasquini L, Di Donato RM. Orthotopic heart transplantation for congenital heart disease: an alternative for high-risk fontan candidates? Circulation 2003; 108 Suppl 1:II140-9. [PMID: 12970223 DOI: 10.1161/01.cir.0000087442.82569.51] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Evaluation of incremental risk factors for early mortality in children undergoing orthotopic heart transplantation (OHT) for congenital heart disease. METHODS Between 1988 and 2002, 43 patients (mean age 9.1+/-7.2 years) underwent 44 OHT for complex TGA (6), DORV (4), single ventricle (21), and other end-stage structural heart disease (11). Two discernible ventricular chambers were present in 18 pts (41.8%). Previous reconstructive or palliative procedures had been previously accomplished in 35 pts (83.3%), including atrial switch (5), systemic-to-pulmonary shunts (10), cavopulmonary anastomosis (9), Fontan completion (6), and others (5). RESULTS 30-day survival for the 2-ventricle subgroup was 94.4+/-5.4% compared with 67.2+/-9.5% for the single ventricle subgroup (P=0.04) (overall 78.6%+/-3.3%). OHT following single ventricle staging to bi-directional cavopulmonary anastomosis exhibited 100% early survival, as opposed to 62.5+/-17.1% for OHT after systemic-to-pulmonary shunts, and 33.3+/-19.2% for OHT following failing Fontan (P=0.010). HLHS diagnosis (0.0085) and failing Fontan (P=0.003) were identified as independent predictors of early mortality by regression logistic modeling, while Fontan stage represented the only predictor of overall mortality by Cox proportional hazard. Overall 10-year survival was 54.3+/-11%. CONCLUSIONS OHT for structural congenital heart disease with single ventricle physiology entails substantial early mortality and bi-directional cavopulmonary anastomosis enables the best transition to heart transplant. OHT should be considered in the decision making process as an alternative to Fontan completion in high-risk candidates, since rescue-OHT after failing Fontan seems unwarranted.
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Affiliation(s)
- Guido Michielon
- Dipartimento Medico-Chirurgico di Cardiochirurgia e Cardiologia Pediatrica, DMCCP, Ospedale Pediatrico Bambino Gesù, Roma, Italy.
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