Pediatric Heart Transplantation: Transitioning to Adult Care

Abstracts S265 of the right-ventricle-pulmonary artery conduit [RV-PAc] in lieu of modified BT shunt; 2) increased use of the hybrid for high risk neonates; 3) aggressive Tx utilization. Results: 114 pts underwent initial palliation at a median age of 6.5 days. Of these, 46 underwent RV-PAc, 45 had BT shunt, and 23 had hybrid. Overall survival improved (58 +/- 0.07% vs. 83 +/- 0.05%, P= 0.015), with 5-year survival among RV-PAc recipients of 90% in Era 2 (Figure). Median followup was 2.2 y (0 - 10.3y), with 78 achieving Stage 2 and 35 achieving Fontan at last follow-up. Thirteen underwent Tx with 1 death. Conclusion: Adoption of a balanced individualized approach for infants with HLHS results in improved midterm survival relative to existing benchmarks. Tx is a vital component of care that can be utilized to improve overall survival and quality of life for selected HLHS patients.

post-tx outcomes with such donors, which underscores the importance of center experience.

6( 99) Center Variability in Selecting High-Risk Donors: Does It Affect the Outcomes in Pediatric Heart Transplantation? R. Rizwan ,1 F. Zafar,1 R. Bryant III,1 C. Chin,2 A. Lorts,2 J.S. Tweddell,1 D.L. Morales.1  1Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; 2Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH. Purpose: High-risk (HR) donors for pediatric heart transplantation (HTx) make up ~15% of the donor pool. We aim to characterize the variability in selecting HR donors among transplant (Tx) centers & to determine if it has an impact on the waitlist (WL) & post Tx outcomes for the centers. Methods: UNOS database (1/1/1994-6/30/2014) was used to identify all pediatric (< 18yo) HTx candidates & recipients. Donor categorization as high-risk was based on ischemic time, death due to cerebrovascular accident, donor to recipient height ratio, left ventricular ejection fraction & renal dysfunction using a previously described Pediatric Heart Donor Assessment Tool (PH-DAT). Centers with < 50 HTx during the study period were excluded. The remaining 34 centers were divided into 3 groups based on utilization of HR donors as: occasional (OU: < 10%), moderate (MU: 10-15%) & regular (RU: > 15%) users of HR donors. WL & post Tx outcomes were compared between the groups. Results: Out of 8324 candidates, OU had 1834 (22%) candidates, MU had 3294 (40%) candidates & RU had 3115 (38%) candidates. Median time on WL was similar between RU & MU (45d vs 46d; p= 0.31) but was less for RU & MU compared to OU (45d vs 55d, p< 0.01 & 46d vs 55d, p< 0.01 respectively). RU are more likely to receive an organ compared to MU (p< 0.01) & OU (p< 0.01), and MU are more likely to receive an organ compared to OU (p= 0.03). Importantly, no difference in post Tx survival was found among the 3 groups (p= 0.14). [Figure A] However, post Tx survival utilizing HR donors was better for RU compared to OU (p= 0.03) & MU (p< 0.01) & was similar between OU & MU (p= 0.96). [Figure B] Conclusion: Centers that utilize more HR donors (RU) have better WL outcomes & maintain similar post-tx outcomes compared to centers that utilize less HR donors (OU & MU). Centers utilizing more HR donors have better

7( 00) Pediatric Heart Transplantation: Transitioning to Adult Care E. Pahl ,1 K. Van't Hof,1 A. Andrei,2 T. Shankel,3 R. Chinnock,3 S. Miyamoto,4 A. Ambardekar,5 L. Addonizio,6 F. Latif,6 D. Lefkowitz,7 L. Goldberg,8 S. Hollander,9 M. Pham,9 K. Grady.10  1Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; 2Northwestern University, Chicago, IL; 3Loma Linda University Medical Center, Loma Linda, CA; 4Children's Hospital Colorado, Aurora, CO; 5University of Colorado Hospital, Aurora, CO; 6Columbia University Medical Center, New York, NY; 7The Children's Hospital of Philadelphia, Philadelphia, PA; 8University of Pennsylvania, Philadelphia, PA; 9Stanford University, Palo Alto, CA; 10Northwestern Memorial Hospital, Chicago, IL. Purpose: Medically complex patients who transition from pediatric to adult care are at high risk for poor outcomes such as repeated hospitalizations and death. Our randomized, controlled, multicenter pilot trial tests an intervention focused on enhancing adherence to improve outcomes for heart transplant (HT) patients (pts) who transfer to adult care. We report baseline findings. Methods: We aim to enroll 100 pts-{50 intervention (INT), 50 usual care (UC)} from six paired pediatric/adult U.S. sites over 3 years with 6 months

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The Journal of Heart and Lung Transplantation, Vol 36, No 4S, April 2017

post transfer follow-up. Our intervention uses computer-based education modules followed by individualized discussion with HT coordinators, and is delivered through 3 months post transfer. Outcomes are: (1) immunosuppression levels, (2) adherence, (3) rejection episodes, (4) use of healthcare resources (ER Visits/Admits). The intervention focuses on enhancing HT knowledge, self-care, self-advocacy and support. Assessments at baseline, 3 months and 6 months post transition include: 1. HT knowledge questionnaire, 2. Transition readiness assessment questionnaire, 3. Social support index and 4. Patient assessment of problems with the HT regimen. Groups were compared via t-tests and chi square. Results: To date, 77/126 screened pts (61%) are enrolled and randomized (38= I NT and 39= U C). Baseline demographics were similar in both study arms: INT vs UC: mean age= 2 1.5+3.3 yrs vs, 21.8+3.5 yrs; female= 4 2% vs 46%; Caucasian= 8 2% vs 72%; >  high school education= 5 5% vs 70%. Most pts in both groups were on tacrolimus based immunosuppression (68 vs 64%). There were no differences between groups at baseline: mean tacrolimus levels INT vs US (6.6+2.4 vs 5.9+3.1); overall self-report of adherence (3.6 vs 3.5 [1= h ardly ever to 4= a ll of the time]); rejection episodes (1 vs 0); hospital re-admissions (7 vs 2; p= 1 1); and no differences regarding HT knowledge, self-care, self-advocacy, and social support. Potential for improvement was similar in both groups. Conclusion: Our pilot trial randomization scheme was effective. There were no significant differences between INT and UC groups for demographics, medical or psychosocial outcomes. Future analyses will inform whether our intervention improves outcomes early after transfer to adult care.

7( 01) Understanding Hypertension in Pediatric Patients After Heart Transplantation P. Patel ,1 K. LaPorte,2 M. Carroll,2 W.T. Mahle,1 K. Kanter,3 S.R. Deshpande.1  1Pediatric Cardiology, Emory University Children's Healthcare of Atlanta, Atlanta, GA; 2Heart Transplantation, Children's Healthcare of Atlanta, Atlanta, GA; 3Department of Cardiothoracic Surgery, Emory University, Atlanta, GA. Purpose: Hypertension (HTN) after heart transplantation (HTx) has been suggested as a risk factor for development of coronary vasculopathy and renal insufficiency. There is no pediatric data regarding HTN post HTx. Aim of this study was to establish clinical epidemiology of post-operative and early HTN in pediatric HTx patients, assess risk factors, and describe therapies. Methods: Retrospective study on 126 consecutive pediatric HTx between 2007-2015. Results: Study population was representative of pediatric HTx ISHLT data. HTN was defined as grthan 95% for age, gender for systolic and diastolic BP. There was very high prevalence of systolic and diastolic HTN in the HTx patients starting immediately after HTx as shown in panel 1 even with parenteral therapies. On post-transplant days 1,2, 5 and 7: 28.6%, 40.5%, 37.3% and 27.8% patients had SBP HTN, respectively and 10.3%, 16,7%, 21.4% and 21.4% patients had DBP HTN, respectively. Overall, hypertension peaked at day 5 post-operatively. At 3 months post-Htx, 28.4% and 26.7% patients had SBP and DBP HTN. At 6 months, 37.5% and 29.5% patients had SBP and DBP HTN respectively. Early therapies were Na-nitroprusside in 68.3% and amlodipine in 81%. At 3 months, 47.4% patients were on amlodipine, 3.4% on ACEI and 3.4% were on both. At 6 months, 42.2% patients were on amlodipine, 2.6% were on ACEI and 3.4% were on both. 47% and 39 % of the patients were on steroids 3 months and 6 months, respectively. In univariate analysis, serum creatinine at day 5 and 7 and steroid use at 6 months were risk factors for persistent HTN. In multivariate regression analysis, only steroid use at 6 months was strongly associated with hypertension (Chi-square value 14.89, p-value-0.001). Conclusion: Hypertension is very common immediately after HTx in pediatric patients and persists at early follow-up with ~ 40% requiring therapy. Postop serum creatinine and steroid use at 6 months are identified as risk factors for hypertension. Study of long term impact and modification of risks is underway.

7( 02) Incidence and Risk Factors for Failed Recovery of Pediatric Donor Hearts A. Ghavam ,1 N. Ghanayem,1 R.K. Woods,2 S.J. Kindel,3 N.E. Thompson.1  1Pediatric Critical Care, Medical College of Wisconsin, Milwaukee, WI; 2Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, WI; 3Pediatric Cardiology, Medical College of Wisconsin, Milwaukee, WI. Purpose: Extensive pre-donation reviews are conducted to determine adequacy of pediatric organ transplantation. The number of donor hearts discarded after acceptance for transplantation is not known. Due to resource utilization necessary for organ recovery and recipient preparation, as well as the emotional distress associated with declining an organ after initial acceptance, we sought to determine the incidence of donor hearts recovered but not transplanted following surgical inspection during procurement. We also attempted to identify modifiable risk factors associated with acceptable donor hearts that were ultimately discarded. Methods: This retrospective observational study utilized data from UNOS from 2000-2015. Donor data was stratified into two groups for analysis: donors with hearts recovered and transplanted, and donors with hearts recovered but discarded prior to transplant. 43 variables were compared in the analysis including demographic data, cause of death, inotropic use, lab studies, and procurement data. Results: Over 15-years, 7,679 pediatric donor hearts were accepted for transplant. Less than 1% (n= 52) was discarded following organ recovery. Demographics, inotrope support, and biochemical abnormalities did not differ between groups. The rate of discarded organs was similar across regions. Donor body mass index was lower in the discarded group compared to the transplanted group (17.8 vs 19.8 kg/m2, p= 0.015). Donor cause of death differed between groups. Head trauma was the most common cause of death in both groups, but isolated CNS tumors made up a larger portion of the discarded group (5.8% vs 0.7%, p< 0.001). Median time from hospital admission to organ recovery was similar between groups at 4 days. When donor hearts were discarded, the heart was the only accepted organ for transplantation. The single most common reason cited for discarding the heart was poor organ function (n= 8, 15%). Thirty (58%) of hearts were discarded for reasons that could not have been accounted for during the pre-transplant evaluation such as recipient status change. Conclusion: The incidence of pediatric donor hearts initially deemed acceptable for transplant but ultimately discarded was low. Modifiable variables at organ evaluation targeted at reducing any loss of donor hearts were not identified. 7( 03) Relationship Between eGFR and Survival Before and After Heart Transplantation in Children R.R. Davies , M.A. McCulloch, C. Brailer, C. Pizarro.  Nemours Cardiac Center, Nemours/A.I. duPont Hospital for Children, Wilmington, DE. Purpose: Renal insufficiency is a risk factor for poor outcomes following pediatric heart transplant (TXPL). However, the risk attributable to various levels of eGFR and whether that risk varies by age has not been delineated.