Development and Validation of a Major Adverse Transplant Event (MATE) Score to Predict Graft Loss after Pediatric Heart Transplantation

Abstract

Purpose: Neurologic complications after heart transplantation (HT) have been reported to occur in greater than 50% of adult HT recipients, but their prevalence and relationship to pre-and peri-transplant conditions remains unclear. We aim to characterize early neurological complications after HT. Methods: We conducted a single center retrospective review of 355 HTs (5 re-transplants) performed at our hospital from late 1994-2014 for the following neurologic complications occurring in the first year after HT: Posterior reversible encephalopathy syndrome (PRES); hemorrhagic or embolic stroke; and isolated seizures. PRES was confirmed by brain MRI in all cases. Univariate and multivariate analysis was done in aggregate. Each individual neurologic complication was analyzed for their relationship to pre and peritransplant conditions, as well as risk of graft loss in the first year after HT. Results: Median age at the time of HT was 5.8 years. 55/355 (15.4%) experienced some neurological event, with PRES comprising 9/55 (16.3%); stroke 28/55 (50.9%); and isolated seizure 18/55 (33.7%). Median time to initial symptoms was 5 days (IQR 3-20 days). Initial symptom was seizure (56%), change in neurologic examination (14%), headache (11%), mental status changes (12%), and other (7%). Multivariate analysis revealed drugtreated hypertension was associated with PRES (OR 7.14, 95% CI 1.69-49.25, p= 0.007) and pre-HT support with ECMO was associated with stroke (OR 5.07, 95% CI 1.52-16.84, p= 0.0014). Isolated seizure was associated with cyclosporine use on univariate analysis (OR 3.86, 95% CI 1.32-11.21, p= 0.0081), but not on multivariate analysis. The presence of any neurologic complication was associated with an increased risk for mortality (OR 2.44, 95% CI 1.09-5.34, p= 0.0306) in the first year after HT. Conclusion: Neurologic complications occur relatively frequently in the first year after pediatric HT. They tend to occur in the first few weeks and are associated with an increased risk for 12 month mortality. Specific neurologic complications demonstrate specific risk profiles that may be amenable to early interventions to reduce risk. Further study in a larger sample size is needed to confirm and extend these findings.