Changing Indications In Pediatric Transplants

SAN DIEGO - Over the past 24 years, the prevalence of indications for pediatric heart transplantation resulting from congenital heart disease has changed. Transplantation for failed SV palliation, including failed Fontan procedure, has now become the predominant indication, according to the observations of a single-center experience reported in the J. Maxwell Chamberlain Memorial Paper for Congenital Heart Surgery at the annual meeting of the Society of Thoracic Surgeons.

Heart transplantation is the only viable treatment for children with end-stage heart failure resulting from either congenital heart disease (CHD) or cardiomyopathy. The purpose of this study by Dr. Rochus K. Voeller and his colleagues at Washington University in St. Louis was to review the trends in the indications for transplant and survival following transplant, using a retrospective review of all 307 orthotopic heart transplants performed at St. Louis Children's Hospital from January 1986 to December 2009. Combined heart-lung transplants were excluded from the study.

The indications for transplantation in 1986-2009 were 39% cardiomyopathy, 57% CHD, and 4% retransplant. Of the 174 patients with CHD, 80% had single-ventricle anomalies (SV). In the CHD group, transplantation for failed SV palliation, including the failed Fontan procedure, became the predominant indication in the latest 8-year interval of their program (increasing from 11% in the 1984-1993 period to 60% in the 2002-2009 period). The rate of retransplantation remained low and unchanged across the various time periods, according to Dr. Voeller.

The mean recipient age was 6.1 years, with 41% of the recipients aged younger than 1 year at the time of transplantation. Nearly one-third of all patients had prior surgical procedures or surgery ranging from banding to Fontan operations; 55% of the patients were boys; 8% of patients were bridged with either ECMO (extracorporeal circulation membrane oxygenation) or VAD (ventricular assist devices).

Overall survival of transplant patients was 81%, 76%, 72%, and 65% at 1, 3, 5, and 10 years, respectively. Survival was best in those patients who were transplanted for cardiomyopathy (1-, 3-, 5-, and 10-year survival of 90%, 84%, 81%, and 81%, respectively) and worst in patients with failed palliations for SV anomalies, especially failed Fontan procedures (1-, 3-, 5-, and 10-year survival of 66%, 61%, 61%, and 53%, respectively).

"Our results demonstrate the high-risk nature of transplants in patients with failed palliations for SV anomalies, including Fontan procedures performed during infancy. As the survival with early palliation for SV anomaly patients improves, more centers will be referred with these patients who will require transplantation at some point," said Dr. Voeller in an interview.

"This will not only impact pediatric heart transplant programs, but it will also influence adult transplant programs as well. Patients following SV palliation, including Fontan procedure, are much more difficult patients to transplant because of a variety of factors. Risk factor analysis will be needed to determine which patients might benefit from earlier transplant referral and how to better prepare these patient for transplant in order to reduce the risk of the procedure," he concluded.

Dr. Voeller reported that none of the authors had any financial disclosures.

SAN DIEGO - Over the past 24 years, the prevalence of indications for pediatric heart transplantation resulting from congenital heart disease has changed. Transplantation for failed SV palliation, including failed Fontan procedure, has now become the predominant indication, according to the observations of a single-center experience reported in the J. Maxwell Chamberlain Memorial Paper for Congenital Heart Surgery at the annual meeting of the Society of Thoracic Surgeons.

Heart transplantation is the only viable treatment for children with end-stage heart failure resulting from either congenital heart disease (CHD) or cardiomyopathy. The purpose of this study by Dr. Rochus K. Voeller and his colleagues at Washington University in St. Louis was to review the trends in the indications for transplant and survival following transplant, using a retrospective review of all 307 orthotopic heart transplants performed at St. Louis Children's Hospital from January 1986 to December 2009. Combined heart-lung transplants were excluded from the study.

The indications for transplantation in 1986-2009 were 39% cardiomyopathy, 57% CHD, and 4% retransplant. Of the 174 patients with CHD, 80% had single-ventricle anomalies (SV). In the CHD group, transplantation for failed SV palliation, including the failed Fontan procedure, became the predominant indication in the latest 8-year interval of their program (increasing from 11% in the 1984-1993 period to 60% in the 2002-2009 period). The rate of retransplantation remained low and unchanged across the various time periods, according to Dr. Voeller.

The mean recipient age was 6.1 years, with 41% of the recipients aged younger than 1 year at the time of transplantation. Nearly one-third of all patients had prior surgical procedures or surgery ranging from banding to Fontan operations; 55% of the patients were boys; 8% of patients were bridged with either ECMO (extracorporeal circulation membrane oxygenation) or VAD (ventricular assist devices).

Overall survival of transplant patients was 81%, 76%, 72%, and 65% at 1, 3, 5, and 10 years, respectively. Survival was best in those patients who were transplanted for cardiomyopathy (1-, 3-, 5-, and 10-year survival of 90%, 84%, 81%, and 81%, respectively) and worst in patients with failed palliations for SV anomalies, especially failed Fontan procedures (1-, 3-, 5-, and 10-year survival of 66%, 61%, 61%, and 53%, respectively).

"Our results demonstrate the high-risk nature of transplants in patients with failed palliations for SV anomalies, including Fontan procedures performed during infancy. As the survival with early palliation for SV anomaly patients improves, more centers will be referred with these patients who will require transplantation at some point," said Dr. Voeller in an interview.

"This will not only impact pediatric heart transplant programs, but it will also influence adult transplant programs as well. Patients following SV palliation, including Fontan procedure, are much more difficult patients to transplant because of a variety of factors. Risk factor analysis will be needed to determine which patients might benefit from earlier transplant referral and how to better prepare these patient for transplant in order to reduce the risk of the procedure," he concluded.

Dr. Voeller reported that none of the authors had any financial disclosures.

SAN DIEGO - Over the past 24 years, the prevalence of indications for pediatric heart transplantation resulting from congenital heart disease has changed. Transplantation for failed SV palliation, including failed Fontan procedure, has now become the predominant indication, according to the observations of a single-center experience reported in the J. Maxwell Chamberlain Memorial Paper for Congenital Heart Surgery at the annual meeting of the Society of Thoracic Surgeons.

Heart transplantation is the only viable treatment for children with end-stage heart failure resulting from either congenital heart disease (CHD) or cardiomyopathy. The purpose of this study by Dr. Rochus K. Voeller and his colleagues at Washington University in St. Louis was to review the trends in the indications for transplant and survival following transplant, using a retrospective review of all 307 orthotopic heart transplants performed at St. Louis Children's Hospital from January 1986 to December 2009. Combined heart-lung transplants were excluded from the study.

The indications for transplantation in 1986-2009 were 39% cardiomyopathy, 57% CHD, and 4% retransplant. Of the 174 patients with CHD, 80% had single-ventricle anomalies (SV). In the CHD group, transplantation for failed SV palliation, including the failed Fontan procedure, became the predominant indication in the latest 8-year interval of their program (increasing from 11% in the 1984-1993 period to 60% in the 2002-2009 period). The rate of retransplantation remained low and unchanged across the various time periods, according to Dr. Voeller.

The mean recipient age was 6.1 years, with 41% of the recipients aged younger than 1 year at the time of transplantation. Nearly one-third of all patients had prior surgical procedures or surgery ranging from banding to Fontan operations; 55% of the patients were boys; 8% of patients were bridged with either ECMO (extracorporeal circulation membrane oxygenation) or VAD (ventricular assist devices).

Overall survival of transplant patients was 81%, 76%, 72%, and 65% at 1, 3, 5, and 10 years, respectively. Survival was best in those patients who were transplanted for cardiomyopathy (1-, 3-, 5-, and 10-year survival of 90%, 84%, 81%, and 81%, respectively) and worst in patients with failed palliations for SV anomalies, especially failed Fontan procedures (1-, 3-, 5-, and 10-year survival of 66%, 61%, 61%, and 53%, respectively).

"Our results demonstrate the high-risk nature of transplants in patients with failed palliations for SV anomalies, including Fontan procedures performed during infancy. As the survival with early palliation for SV anomaly patients improves, more centers will be referred with these patients who will require transplantation at some point," said Dr. Voeller in an interview.

"This will not only impact pediatric heart transplant programs, but it will also influence adult transplant programs as well. Patients following SV palliation, including Fontan procedure, are much more difficult patients to transplant because of a variety of factors. Risk factor analysis will be needed to determine which patients might benefit from earlier transplant referral and how to better prepare these patient for transplant in order to reduce the risk of the procedure," he concluded.

Dr. Voeller reported that none of the authors had any financial disclosures.