Current state of pediatric cardiac transplantation

Abstract

Pediatric heart transplantation is standard of care for children with end-stage heart failure. The diverse age range, diagnoses, and practice variations continue to challenge the development of evidence-based practices and new technologies. Outcomes in the most recent era are excellent, especially with the more widespread use of ventricular assist devices (VADs). Waitlist mortality remains high and knowledge of risk factors for death while waiting and following transplantation contributes to decision-making around transplant candidacy and timing of listing. The biggest gap impacting both waitlist and overall survival remains mechanical support options for infants and patients with single ventricle physiology. Though acute rejection has decreased progressively, both diagnosis and management of antibody-mediated rejection has become increasingly challenging and complex, as has the ability to understand the implication of anti-HLA antibodies detected both pre-and post-transplantation-including when and how to intervene. Trends in immunosuppression protocols include more use of induction therapy and steroid avoidance or withdrawal protocols. Common long-term morbidities include renal insufficiency, which can be mitigated with surveillance and renal-sparing strategies, and infections. Functional outcomes are excellent, but significant psychosocial challenges exist in relation to neurodevelopment, non-adherence, and transition from childcentered to adult-centered care. Cardiac allograft vasculopathy (CAV) remains a barrier to long-term survival, though it is more apparent that objective evidence of an impact on the allograft is important with regards to impact on outcomes. Retransplantation is rare in pediatric heart transplant recipients. Pediatric heart transplantation continues to evolve in order to address the challenges of the diverse group of patients that reach end-stage heart failure during childhood.

Cardiac transplantation in children

“…The International Registry of Paediatric Heart and Lung Transplantation (ISHLT) is the largest registry to collect data regarding cardiac transplantation in children. 1 Figures stated in this article will be from this database unless stated otherwise. The number of cardiac transplants in children has increased annually from 414 in 2000 to 684 in 2015.…”

“…Multiple studies have demonstrated equivalent outcomes from ABO-compatible and -incompatible transplants in small children. 1 Successful transplantation of ABO-incompatible organs requires three factors: specialist techniques to reduce the isohaemagglutinins titres before reperfusion of the new organ place; effective immunosuppression; and early treatment of antibody-mediated rejection (AMR).…”

“…It is often difficult to differentiate in clinical practice between the two. 1 Episodes of hyperacute rejection are rare thanks to calculated risks regarding ABO and HLA compatibility. There are few identifiable risk factors for rejection other than sensitisation.…”

“…There are few identifiable risk factors for rejection other than sensitisation. 1 Early rejection episodes are associated with a worse 10-yr survival. 2 The gold standard for diagnosis of rejection is endomyocardial biopsy and transplant centres will deploy their own surveillance strategy.…”

Paediatric donation after circulatory determined death heart transplantation using donor normothermic regional perfusion and ex situ heart perfusion: A case report

“…In contrast, the survival outcomes following subarachnoid haemorrhage and severe neurotrauma have improved with reducing mortality after head injury . The number of heart transplants has remained fairly constant, with waiting list mortality for paediatric patients awaiting heart transplantation at 1 year remains at 17% and as high as 30% in the infant group . This unacceptable waiting list mortality led us to perform transplant using a DCD donor, which currently account for <0.05% of paediatric heart transplants …”