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Thangappan K, Zafar F, Ahmed HF, Greenberg JW, Ashfaq A, Hirsch R, Chin C, Lehenbauer D, O'Donnell A, Morales DLS. Is the practice of using oversized organs for recipients with elevated pulmonary vascular resistance justified? J Thorac Cardiovasc Surg 2023; 166:1766-1779. [PMID: 36163295 DOI: 10.1016/j.jtcvs.2022.04.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 04/05/2022] [Accepted: 04/12/2022] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The purpose of this study was to assess post-transplantation outcomes in recipients with increased pulmonary vascular resistance (PVR) in relation to donor size. METHODS The United Network for Organ Sharing database was used to identify patients ages 0 to 18 years at time of listing who underwent transplantation from 2010 to 2019 and for whom cardiac catheterization and donor-recipient weight ratio data were available. Patients were divided according to listing PVR into <3, 3 to 6, and >6 Wood units. Donor-recipient weight ratio was categorized as undersized (≤0.80), midsize (0.81-1.2), and oversized (>1.2). Subgroup analysis was done with an additional supersized group (>2.0). RESULTS Fourteen hundred ninety-one patients met study criteria. Median age was 10 (interquartile range, 3-15) years and 45% were female. Four percent of heart transplantation cases used undersized, 45% used midsize, and 51% used oversized organs. More patients with PVR >6 were received an oversized organ transplant compared with patients with PVR <3; 59% (148/252) versus 48% (430/894); P = .003. There was no difference in survival among organ size groups regardless of PVR; this includes patients with PVR >6 at listing who received an oversized organ transplant versus an undersized (P = .359) or midsized (P = .956) organ. In subgroup analysis, even in patients who received a supersized organ transplant, there was no survival difference noted regardless of PVR. CONCLUSIONS Despite a persistent practice pattern to transplant oversized organs in high-PVR patients, there remains no difference in post-transplantation survival among these patients and those who received smaller organ transplants. Therefore, transplants in patients with high PVR should not be delayed by waiting for larger donors.
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Affiliation(s)
- Karthik Thangappan
- Department of Cardiovascular Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Farhan Zafar
- Department of Cardiovascular Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Hosam F Ahmed
- Department of Cardiovascular Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jason W Greenberg
- Department of Cardiovascular Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Awais Ashfaq
- Department of Cardiovascular Surgery, Johns Hopkins All Children's Hospital, St Petersburg, Fla
| | - Russel Hirsch
- Department of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Clifford Chin
- Department of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David Lehenbauer
- Department of Cardiovascular Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Alan O'Donnell
- Department of Cardiovascular Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David L S Morales
- Department of Cardiovascular Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
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Hopper RK, van der Have O, Hollander SA, Dipchand AI, Perez de Sa V, Feinstein JA, Tran-Lundmark K. International practice heterogeneity in pre-transplant management of pulmonary hypertension related to pediatric left heart disease. Pediatr Transplant 2023; 27:e14461. [PMID: 36593638 DOI: 10.1111/petr.14461] [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: 10/09/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Elevated pulmonary vascular resistance (PVR) in the setting of left heart failure may contribute to poor outcomes after pediatric heart transplant (HTx), but peri-transplant management is variable. METHODS We sought to characterize international practice by surveying physicians at pediatric HTx centers. RESULTS We received 49 complete responses from 39 centers in 16 countries. Most respondents are pediatric cardiologists (90%), practice at centers offering heart (86%) and lung (55%) transplant, and perform pre-HTx acute vasoreactivity testing (AVT, 88%) in patients with elevated PVR. Half (51%) reported defining a PVR cutoff for HTx eligibility as ≤6 WU m2 (56%) post-AVT (84%). The highest post-AVT PVR ever accepted for HTx ranged from 3-14.4 (median 6) WU m2 . To treat elevated pre-transplant PVR, phosphodiesterase type 5 inhibitors are most common (65%) followed by oxygen (31%), nitric oxide (14%), endothelin receptor antagonists (11%), and prostacyclins (6%). Nearly a third (31%) do not routinely use pulmonary vasodilators without implantation of a left ventricular assist device (LVAD). Case scenarios highlight treatment variability: in a restrictive cardiomyopathy scenario, HTx listing with post-transplant vasodilator therapy was favored, whereas in a Shone's complex patient with fixed PVR, LVAD ± pulmonary vasodilators followed by repeat catheterization was most common. Management of dilated cardiomyopathy with reactive PVR was variable. Most continue vasodilator therapy until HTx (16%), PVR normalizes (16%) or ≤6 months. CONCLUSIONS Management of elevated PVR in children awaiting HTx is heterogenous. Evidence-based guidelines are needed to allow for longitudinal determination of optimal outcomes and standardized care.
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Affiliation(s)
- Rachel K Hopper
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California, USA
| | - Oscar van der Have
- Department of Experimental Medical Science, Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden.,The Pediatric Heart Center, Skane University Hospital, Lund, Sweden
| | - Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California, USA
| | - Anne I Dipchand
- Department of Pediatrics, Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Valeria Perez de Sa
- Department of Clinical Sciences, Anesthesiology and Intensive Care, Lund University, Lund, Sweden
| | - Jeffrey A Feinstein
- Department of Pediatrics (Cardiology), Stanford University School of Medicine, Palo Alto, California, USA
| | - Karin Tran-Lundmark
- Department of Experimental Medical Science, Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden.,The Pediatric Heart Center, Skane University Hospital, Lund, Sweden
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Balakrishnan KR, Rao KGS, Subramaniam GK, Tanguturu MK, Arvind A, Ramanan V, Dhushyanthan J, Ramasubramanian K, Kumaran KS, Sellamuthu G, Rajam M, Mettur S, Gnansekharan P, Ratnagiri R. Clinical profiles and risk factors for early and medium-term mortality following heart transplantation in a pediatric population: A single-center experience. Ann Pediatr Cardiol 2021; 14:42-52. [PMID: 33679060 PMCID: PMC7918032 DOI: 10.4103/apc.apc_129_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 07/30/2020] [Accepted: 11/27/2020] [Indexed: 11/24/2022] Open
Abstract
AIMS AND OBJECTIVES There is a paucity of data regarding the outcomes of Heart transplantation in children from the Indian subcontinent. The data of patients under the age of 18 undergoing an isolated heart transplantation was analyzed for patient clinical profiles and risk factors for early and medium-term mortality. Hospital mortality was defined as death within 90 days of transplantation and medium-term survival as follow up of up to 6 years. MATERIALS AND METHODS A total of 97 patients operated between March 2014 and October 2019 were included in this study. Data was collected about their INTERMACS status, pulmonary vascular resistance, donor heart ischemic times, donor age, donor to recipient weight ratio and creatinine levels. RESULTS The age range was from 1 to 18 with a mean of 10.6 ± 4.6 years. 67 % patients were in INTERMACS category 3 or less.12 children were on mechanical circulatory support at the time of transplant. The 90 day survival was 89 %. The risk factors for hospital mortality was lower INTERMACS category (odd's ratio 0.2143, P = 0.026), elevated creatinine (odd's ratio 5.42, P = 0.076) and elevated right atrial pressure (odd's ratio 1.19, P = 0.015). Ischemic time, pulmonary vascular resistance (PVR) and PVR index (PVRI) had no effect on 90 day survival. Kaplan Meier estimates for 5 year survival was 73 %. The medium term survival was affected by INTERMACS category (Hazard ratio 0.7, P = .078), donor age > 25 (Hazard ratio 1.6, P = 0.26) and raised serum creatinine values.(Hazard ratio 2.7, P = 0.012). All the survivors are in good functional class. CONCLUSIONS Excellent outcomes are possible after heart transplantation in a pediatric population even in a resource constrained environment of a developing economy. More efforts are needed to promote pediatric organ donation and patients need to be referred in better INTERMACS category for optimal outcomes.
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Affiliation(s)
- Komarakshi R. Balakrishnan
- Department of Pediatric Cardiac Surgery, Institute of Heart and Lung Transplantation, MGM Health Care, Chennai, Tamil Nadu, India
| | - Kemundel Genny Suresh Rao
- Department of Pediatric Cardiac Surgery, Institute of Heart and Lung Transplantation, MGM Health Care, Chennai, Tamil Nadu, India
| | - Ganapathy Krishnan Subramaniam
- Department of Pediatric Cardiac Surgery, Institute of Heart and Lung Transplantation, MGM Health Care, Chennai, Tamil Nadu, India
| | - Murali Krishna Tanguturu
- Department of Pediatric Cardiac Surgery, Institute of Heart and Lung Transplantation, MGM Health Care, Chennai, Tamil Nadu, India
| | - Ajay Arvind
- Department of Pediatric Cardiac Surgery, Institute of Heart and Lung Transplantation, MGM Health Care, Chennai, Tamil Nadu, India
| | - Veena Ramanan
- Department of Pediatric Cardiac Surgery, Institute of Heart and Lung Transplantation, MGM Health Care, Chennai, Tamil Nadu, India
| | - Jagdish Dhushyanthan
- Department of Pediatric Cardiac Surgery, Institute of Heart and Lung Transplantation, MGM Health Care, Chennai, Tamil Nadu, India
| | - K. Ramasubramanian
- Department of Pediatric Cardiac Surgery, Institute of Heart and Lung Transplantation, MGM Health Care, Chennai, Tamil Nadu, India
| | - K. Suresh Kumaran
- Department of Pediatric Cardiac Surgery, Institute of Heart and Lung Transplantation, MGM Health Care, Chennai, Tamil Nadu, India
| | - Gunalan Sellamuthu
- Department of Pediatric Cardiac Surgery, Institute of Heart and Lung Transplantation, MGM Health Care, Chennai, Tamil Nadu, India
| | - Mohan Rajam
- Department of Pediatric Cardiac Surgery, Institute of Heart and Lung Transplantation, MGM Health Care, Chennai, Tamil Nadu, India
| | - Senthil Mettur
- Department of Pediatric Cardiac Surgery, Institute of Heart and Lung Transplantation, MGM Health Care, Chennai, Tamil Nadu, India
| | - Pradeep Gnansekharan
- Department of Pediatric Cardiac Surgery, Institute of Heart and Lung Transplantation, MGM Health Care, Chennai, Tamil Nadu, India
| | - Ravikumar Ratnagiri
- Department of Pediatric Cardiac Surgery, Institute of Heart and Lung Transplantation, MGM Health Care, Chennai, Tamil Nadu, India
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Albers EL, Bradford MC, Friedland-Little JM, Hong BJ, Kemna MS, Chen JM, Law YM. Diastolic pressure indices offer a novel approach to predicting risk of graft loss after pediatric heart transplant. Pediatr Transplant 2018; 22. [PMID: 29396892 DOI: 10.1111/petr.13126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2017] [Indexed: 11/28/2022]
Abstract
PH is a risk factor for GL after HTx. However, traditional parameters are not reliable predictors of risk in children. We hypothesized that DPI (dPAP and DPG) are predictive of GL in pediatric HTx recipients. The UNOS/SRTR database was reviewed to identify pediatric HTx recipients (age <18 years) between 1994 and 2013. Recipients with pretransplant hemodynamic data were grouped by diagnosis (CMP or CHD), and the groups were analyzed separately. Bivariate Cox regression analysis examined the association between hemodynamic variables and GL. DPI showed the strongest association with early GL in recipients with CMP (dPAP: HR = 1.25 [1.09-1.42]; DPG: 1.24 [1.11-1.38]). Among CHD recipients, DPI were associated with early GL in those with preexisting PH (dPAP: HR = 1.16 [1.01-1.33]; DPG: HR = 1.10 [1.00-1.21]). No cutoff values for "high-risk" DPI were identified, but a continuous relationship between higher DPI and risk of early GL was observed. DPI are associated with early GL in select pediatric HTx recipients. Our findings suggest that DPI should be considered as part of routine hemodynamic assessment for pediatric HTx candidates.
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Affiliation(s)
- Erin L Albers
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
| | | | | | - Borah J Hong
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
| | - Mariska S Kemna
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
| | - Jonathan M Chen
- Division of Pediatric Cardiothoracic Surgery, Seattle Children's Hospital, Seattle, WA, USA
| | - Yuk M Law
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
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Castleberry C, Canter CE. The influence of pulmonary resistance on the success of pediatric heart transplantation: Are there still boundaries? Pediatr Transplant 2015. [PMID: 26215796 DOI: 10.1111/petr.12560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Chesney Castleberry
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA.
| | - Charles E Canter
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
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