Sensitization to human leukocyte antigens (HLA) is a risk factor for adverse outcomes after heart transplantation. Requiring a negative prospective crossmatch results in longer waiting times and increased waitlist mortality. We report outcomes in a cohort of sensitized children who underwent transplant despite a positive complement dependent cytotoxicity (CDC) crossmatch (CM+) using a protocol of antibody depletion at time of transplant, followed by serial intravenous immunoglobulin administration. All patients less than 21 years old who underwent heart transplantation at Boston Children’s Hospital from 1/1998-1/2011 were included. We compared freedom from allograft loss, allograft rejection, and serious infection between CM+ and CM− recipients. Of 134 patients in the cohort, 33 (25%) were sensitized prior to transplantation and 12 (9%) received a CM+ heart transplant. Serious infection in the first post-transplant year was more prevalent in the CM+ patients compared to CM− patients (50% vs. 16%;P=0.005), as was hemodynamically significant antibody mediated rejection (50% vs. 2%;P<0.001). There was no difference in freedom from allograft loss or any rejection. At our center, children transplanted despite a positive crossmatch had acceptable allograft survival and risk of any rejection, but a higher risk of hemodynamically significant antibody-mediated rejection and serious infection.

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Cardioplegia is an integral and essential method of myocardial protection for patients of all ages requiring cardiac surgery in which the heart must be stopped. Numerous cardioplegia solutions and delivery methods have been developed. The del Nido cardioplegia solution has been in use for 18 years at Boston Children’s Hospital. This is a unique four parts crystalloid to one part whole blood formulation that is generally used in a single-dose fashion. Although the formulation was originally developed for use in pediatric and infant patients, its use for adult cardiac surgery has been expanding. National and international inquiries to our institution regarding this cardioplegia have been increasing over the last 2 years. We present the developmental history, supporting theory, and current protocol for use of what is now referred to as del Nido cardioplegia.

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