Heart Transplantation in Children after Mechanical Circulatory Support: Comparison of Heart Transplantation with Ventricular Assist Devices and Elective Heart Transplantation

Abstract

Heart transplantation (HTx) is an ultimate treatment for children with end-stage heart failure or inoperable congenital heart disease. The supply of hearts is inadequate; therefore, different mechanical support systems must be used as bridge to HTx in pediatric patients with postoperative low output. The use of ventricular assist devices (VADs) as bridge to HTx in children is limited because of size differences. The purpose of this study was to evaluate the overall long-term outcome of pediatric circulatory support before pediatric HTx. From 1989 through 2004, 91 pediatric patients underwent isolated HTx. Seven of them required mechanical support before transplantation. We reviewed retrospectively the course of 91 children (mean age 14.7 years) who underwent HTx. Group A consisted of elective HTx patients who were treated as outpatients before HTx, whereas group B was the VAD-HTx bridging group (n=7; mean age 12.31 +/- 2.8 years). Mean duration of VAD support was 108 +/- 98 days (minimum 1 day, maximum 258 days). Overall survival rate after HTx was 80% at 1 year without significant differences between groups. Five of seven patients survived and could be discharged after successful HTx, for a survival rate of 77%. The mean follow-up period was 16.76 +/- 10.6 months. No differences in posttransplantation long-term survival and rejection episodes occurred between patients transplanted with or without VAD. VAD therapy can keep pediatric patients with end-stage heart failure alive until successful HTx, and bridge to HTx is a safe procedure in pediatric patients. After HTx, survival rates of these children are similar to those of patients awaiting elective HTx.

Outcome of Heart Transplantation in Pediatric Recipients

“…After HTx, the survival rates of these children are similar to those of patients awaiting elective HTx. 10 Some physicians still believe in the myth that immunosuppression after transplantation could lead to growth retardation and tumor formation. Actually, it might be a problem but not an obstacle.…”

Historical review and perspectives in pediatric transplantation

“…Heart transplantation was succeeded in 10 cases (35%), whereas the other patients died during the support [49]. In another study of 91 pediatric patients who underwent isolated heart transplant [50 ], seven received assistance before heart transplant (mean duration 108 AE 98 days) and 84 were treated as outpatients before heart transplant. Overall survival was 80% at 1 year, without significant difference between the groups.…”

Pediatric ventricular assist device use as a bridge to transplantation does not affect long-term quality of life

“…3 VADs have been shown to improve survival to transplantation compared with extracorporeal membrane oxygenation (ECMO). 4,5 VAD use as a bridge to transplantation (BTT) has had equal or better rates of post-transplantation survival compared to medical therapy alone as a BTT, [6][7][8][9][10][11][12][13] although the outcome data have been limited. With the efficacy of adult and pediatric VAD use established, it is appropriate to assess the long-term outcomes beyond survival alone.…”