Pediatric heart‐lung transplantation: A contemporary analysis of outcomes

Abstract

Background Pediatric heart‐lung transplantation (HLT) is rare, and no report has analyzed patient outcomes since time of listing. We analyzed pediatric HLTs to understand risk factors for waitlist and post‐HLT mortality. Methods All pediatric (<18 year old) HLT candidates were identified within the UNOS database (n = 573) and grouped by age, era, and by diagnosis. Logistical regression and Cox proportional hazard modeling identified risk factors for 6‐month WL and overall post‐transplant mortality. Results 209/573 (37%) HLT candidates were transplanted, 7% recovered, 42% died waiting, and 15% were removed for another/unknown reason. Diagnoses were primary pulmonary hypertension(n = 130), congenital heart disease(CHD) without Eisenmenger's syndrome (ES) (n = 65), CHD with ES (n = 73), and other (n = 305). Patients with a diagnosis other than CHD with ES (OR: 7.55, P = .001), on IV inotropic support (OR: 2.79, P < .001), and infants (OR: 2.20, P = .004) were associated with waitlist mortality. There has been a 56% reduction in HLTs across eras (Era 1:10.8/yr vs Era 2:4.7/yr). Risk factors for post‐transplant mortality were ECMO (HR: 4.1, P = .016), and being infant (HR: 2.2, P = .04) or 1‐11 years old (HR: 1.78, P = .015). ECMO patients have an 87% 2‐year mortality rate with a median post‐transplant survival of 64 days. Overall, post‐transplant survival was unchanged (log‐rank P = .067) between eras. Excluding ECMO patients, in the recent era 29 non‐infant patients with primary pulmonary hypertension had 93% 1‐year survival and 67% 5‐year survival. Conclusions Nearly 600 pediatric patients have been listed for HLT in UNOS, although numbers are decreasing in the current era. HLT for a patient on ECMO appears to be an ineffective strategy; however, in well‐selected cohorts, HLT can provide considerable post‐transplant survival.

International practice heterogeneity in pre‐transplant management of pulmonary hypertension related to pediatric left heart disease

“…The majority of physician respondents reported using pulmonary vasodilators for some children with heart failure and elevated PVR, with that number increasing in the presence of an LVAD. Interestingly, there was a low percentage of respondents recommending listing for combined heart–lung transplant in all three survey case scenarios, reflecting a generalized sense that VAD support is preferable given its overall improved survival 15 …”

Pediatric impacts of multiorgan transplant allocation policy in the United States

“…16 In a recent analysis by Riggs et al, nearly 600 pediatric patients have been listed for heart-lung transplant in UNOS since 1985. 17…”

“…Overall, worldwide pediatric heart–lung survival has improved with a 5‐year survival rate of 49% in the 2000s 16 . In a recent analysis by Riggs et al, nearly 600 pediatric patients have been listed for heart–lung transplant in UNOS since 1985 17 . Primary diagnoses for pediatric heart–lung candidates include pulmonary hypertension, congenital heart disease without Eisenmenger syndrome, congenital heart disease with Eisenmenger syndrome, and re‐transplantation.…”

Extracorporeal membrane oxygenation and paracorporeal lung assist devices as a bridge to pediatric lung transplantation

“…For patients on ECMO, waitlist times were shorter, but post‐transplant survival was only 13% after 2 years post‐of transplantation. The authors concluded that with only a small number of HLTs being performed and such guarded survival expectations, other medical therapies might be considered as a bridge to transplant in place of ECMO, such as ventricular assist devices, total artificial hearts, and paracorporeal/intrathoracic artificial lungs 51 …”

“…The authors concluded that with only a small number of HLTs being performed and such guarded survival expectations, other medical therapies might be considered as a bridge to transplant in place of ECMO, such as ventricular assist devices, total artificial hearts, and paracorporeal/intrathoracic artificial lungs. 51 When to discontinue the bridging strategy is not well established. Lancaster et al 3 have described that the median duration of ECMO support in adult series is about 10-18 days, much shorter than the average pediatric waitlist time.…”