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Pulmonary venous Doppler patterns in pediatric cadaveric and living-donor lung transplantation
82
Abstracts
cial correlates of smoking relapse were persistent or recurrent psychiatric distress (depression, anxiety) (r⫽.21) and caregiver (usually spouse) smoking (r⫽.21). Caregiver smoking was the only significant predictor of recipient relapse (B⫽.913. Smoking history is emerging as a significant health risk to organ txp recipients; risk of relapse is unknown. These findings underscore the need for further study of post-txp smokers and early intervention programs, involving not only recipients but also their caregivers. 75 ORTHOTOPIC TRANSPLANTATION FOR DEXTROCARDIA AND COMPLEX CONGENITAL HEART DISEASE J. Odim, J. Alejos, A. Alikhani, C. Burch, H. Laks, Surgery, University of California at Los Angeles, Los Angeles, CA Background: Despite steady progress in the results of children undergoing orthotopic heart transplantation, most series report better outcome in individuals with noncongenital cardiomyopathy. We sought to review our experience with this difficult subset of patients with complex congenital heart disease and dextrocardia. Methods: Seven children with dextrocardia have undergone 8 orthotopic heart transplants at our institution over the last 15 years. We retrospectively review their outcome. Results: Three boys and four girls each underwent transplantation at a mean age of 9.3 years (range, 3 to 16). The mean donor/recipient weight and height ratios were 1.08 (range,0.31 to 1.33) and 1.52 (range, 0.31 to 3.12) respectively. The mean donor ischemia time was 305 minutes (range, 255 to 390). Synthetic and biologic conduit material was used to preserve unobstructed systemic and pulmonary venous pathways. Immunosuppression consisted of CyA or Tacrolimus-based triple drug therapy (with azathioprine and prednisone). The mean number of rejection episodes per child was 0.7 (range, 0 to 2). No patient has developed systemic or pulmonary venous pathway obstruction. No patient has developed obstruction of the great vessels. One child required a pericardial window for a large effusion 3 weeks after transplantation. No patient has required further cardiac surgery or interventional cardiology. One patient required transplantation 3 years following the initial allograft because of coronary artery vasculopathy. There was one early and no late deaths at a mean follow-up period of 58 months (range,0.5 to 175). Conclusion: The usual levocardiac orientation of donor allografts makes orthotopic transplantation for endstage complex congenital heart disease and dextrocardia technically challenging. The early and intermediate term results in this subset of children are excellent and justify the clinical investment. Children with complex congenital heart defects, dextrocardia and anomalies of pulmonary and systemic venous relationships can undergo successful orthotopic heart transplantation. When end-stage heart failure supervenes, OHT should be considered a viable therapy. 76 BRONCHIAL ANASTOMOSIS COMPLICATIONS: COMPARISON BETWEEN PEDIATRIC LIVING DONOR DOUBLE LOBAR LUNG TRANSPLANT AND CADAVERIC DOUBLE LUNG RECIPIENTS J. Markley, W.J. Wells, M.V. Horn, V.A. Starnes, M.S. Woo, Cardiothoracic Surgery, Childrens Hospital Los Angeles, Los Angeles, CA
The Journal of Heart and Lung Transplantation January 2002 Pediatric living donor lobar lung transplant(LD) recipients receive lower lobes from 2 healthy adult donors. The size mismatch between the pediatric recipient to adult donor bronchi may increase the risk of anastomosis complications in LD recipients compared to cadaveric double lung (CL) transplant patients. We retrospectively reviewed all pediatric double lung transplant recipients who survived at least 1 year after surgery. All lung transplantation was performed by the same surgeon (VAS). All LD and 14/15 CL procedures were done with patients on cardiopulmonary bypass (CPB). Anastomosis complications were directly identified by bronchoscopy. 43 patients met inclusion criteria. 28 patients underwent LD transplant (12 males:16 females; mean age 14.7 ⫾ 3.6 years; 24 cystic fibrosis/4 pulmonary hypertension) and 15 patients had CL transplantation(7 males:8 females; mean age 13.0 ⫾ 6.1 years; 8 cystic fibrosis/2 pulmonary hypertension; 1 each with surfactant protein B deficiency, A-V malformation, non-transplant related obliterative bronchiolitis, idiopathic pulmonary fibrosis, and idiopathic pulmonary hemosiderosis). There was no significant difference in LD versus CL ages at time of transplant (p ⫽ 0.17, ns). A total of 6/43 (14%) patients had anastomosis complications. 2/28 (7%) LD patients had bronchial stenosis (right bronchial anastomosis) compared to 4/15 (27%) CL recipients (2 with right bronchial stenosis; 2 with bronchial stenosis bilaterally). LD mean ischemic time was significantly shorter than the CL ischemic times (79.3 ⫾ 21.8 minutes versus CL ischemic time of 193.3 ⫾ 66.0 minutes; p ⬍ 0.01). LD CPB time was 129.2 ⫾ 27.4 minutes versus CL CPB time of 112.9 ⫾ 37.9 minutes (p ⫽ 0.12, ns). None of the patients required revision of the anastomosis or stent placement. We conclude that pediatric LD recipients do not have a higher incidence of airway anastomosis complications compared to CL recipients. We speculate that transplant surgical experience, along with significantly lower ischemic time, reduces the risk of stenosis in pediatric LD recipients. 77 PULMONARY VENOUS DOPPLER PATTERNS IN PEDIATRIC CADAVERIC AND LIVING-DONOR LUNG TRANSPLANTATION A.M. Sharkey, M.C. Johnson, R. Hirsch, C.B. Huddleston, E.N. Mendeloff, 1Division of Pediatric Cardiology, Washington University, St Louis, MO; 2Pediatric Cardiothoracic Surgery, Washington University, St Louis, MO Purpose: Direct anastamosis of the pulmonary veins to the left atrium in living-donor lung transplantation (LDLT) may be more susceptible to torque or narrowing at suture lines than the cuff anastomosis of cadaveric lung transplantation (CLT). Perioperative TEE evaluation of these anastomotic sites is an important adjunct in the management of these patients. Methods: Perioperative TEE and pulmonary venous Doppler interrogations (VDI) were performed in 10 patients undergoing LDLT (mean age 14.3yr) and compared with 9 patients undergoing bilateral CLT (mean age 9.4yr). Perfusion scan and available cardiac catheterization data were also reviewed. Results: Peak flow velocities for both lungs were increased in patients following LDLT compared with CLT (L lung 157⫹/-29 vs 90⫹/-40 cm/sec; R lung 142⫹/-41 vs 79⫹/-22 cm/sec, p⬍0.01). There was no significant difference in VDI within LDLT or CLT. The VDI abnormalities and associated clinical course prompted cardiac catheterization in 4 patients (3 LDLT, 1 CLT). Three patients had balloon dilation of stenotic segmental veins, in all
The Journal of Heart and Lung Transplantation Volume 21, Number 1 cases pulmonary venous obstruction was accurately predicted by VDI on TEE. Conclusion: Pulmonary venous Doppler velocities are significantly increased in LDLT. VDI elevated beyond these ‘normal’ ranges should lead to a high index of suspicion for pulmonary vein stenosis. Elevated VDI, when associated with changing/ asymmetric perfusion imaging and protracted clinical course, should prompt further therapeutic interventions. 78 NON-INVASIVE DETECTION OF CORONARY ARTERY DISEASE BY DOBUTAMINE STRESS ECHOCARDIOGRAPHY IN CHILDREN AFTER HEART TRANSPLANTATION S. Di Filippo, M. Raboisson, F. Sassolas, A. Bozio, Pediatric Cardiology, Ho ˆpital Cardiologique Louis Pradel, Lyon, France Background: Coronary vasculopathy is the main cause cardiac graft failure. As yearly coronary angiography is invasive in children, a non-invasive method for detecting graft vasculopathy is needed. The aim of this study was to test Dobutamine-Stress Echocardiography (DSE) in a pediatric population, to assess its feasibility, safety and reliability in the detection of graft coronary artery disease. Methods: Eighteen patients, aged 2 days to 16.8 years at transplantation (mean 8.4 years) underwent 44 DSEs at a follow-up of 1.1 to 11.8 years (mean 5.1 years). Selective coronary angiography was performed for comparison. Echocardiographic recordings were obtained in 4 standard views of the left ventricle and measurements carried out within the frames of a 16-segment model. Segmental scores of contractility were obtained for each segment at each stage and a total segmental contractility index was calculated. Results: All patients reached the maximum dose-stage. No major complication occured. Maximum heart rate was 57% to 89% of predicted maximum. Maximum systolic blood pressure reached 190mmHg. Segmental scores were normal in 37 cases and abnormal in 7 cases. DSE results were concordant with angiography in 82% of the cases and discordant in 18% of the cases ( 4 negative DSEs with abnormal angiography and 2 positive DSEs with normal angiography) but there was no significant angiographic lesion with normal DSE. Conclusion: According to our study, DSE is a safe and easily feasible non-invasive method for detection of coronary vasculopathy in transplanted children. It seems to predict significant angiographic lesions but further larger studies are needed to demonstrate its reliability for detecting graft ischemia in children. 79 SEVERE OBLITERATIVE BRONCHIOLITIS IS ASSOCIATED WITH TRANSPLANT CORONARY ARTERY DISEASE IN PEDIATRIC HEART-LUNG RECIPIENTS P.D. Wearden,1 S.A. Webber,2 S.K. Gandhi,1 G.J. Boyle,2 Y.M. Law,2 S. Miller,2 P. Dickman,3 R.D. Siewers,1 F.A. Pigula,1 1 Cardiothoracic Surgery; 2Cardiology; 3Pathology, Children’s Hospital of Pittsburgh, Pittsburgh, PA Background: Acute rejection of the heart in the absence of concomitant lung rejection is thought to be uncommon in heartlung transplant (HLTx) recipients. The association between chronic rejection of the lung, obliterative bronchiolitis (OB) and
Abstracts
83
chronic rejection of the heart, transplant coronary artery disease (TxCAD), is less well known. Methods: A retrospective review of all patients undergoing HLTx at a single institution was performed. TxCAD was correlated with OB by histologic findings in autopsy and pathology specimens. Results: Thirty-six HLTxs were performed in 34 patients since 1985. Indications included congenital heart disease with pulmonary hypertension (17/34, 50%), primary pulmonary hypertension (14/34, 41%) and primary lung disease (3/34, 9%). The mean age at transplantation was 11.6 ⫾ 1 years and the mean follow-up period was 54 ⫾ 9 months. The Kaplan-Meier 1, 3 and 5 year survival was 71%, 62% and 43% respectively. Ten patients died in the perioperative period. One patient died from pneumonia one year following transplantation. Thirteen patients died as a result of complications from OB. No patient died as a direct result of cardiac rejection. There are 10 surviving patients. The freedom from OB at 1, 3 and 5 years was 79%, 48% and 32% and survival after the diagnosis of OB was 82%, 65% and 24% at the same time intervals. None of the patients experienced acute cardiac rejection. Of the 13 patients who died as a result of OB, 9 autopsies were available. All of these specimens demonstrated severe OB. The transplanted hearts were noted to have severe (3), moderate (3), mild (2) or no (1) TxCAD. Conclusions: In pediatric HLTx recipients, acute or chronic cardiac rejection was not found in the abscence of lung rejection; thus, surveillance heart biopsy is unwarranted. While OB is the cause of the greatest late mortality, moderate to severe TxCAD was found at autopsy in two-thirds of the specimens. This finding may have important implications when evaluating patients for repeat HLTx or double lung Tx following HLTx. 80 THYMOGLOBULINE威 USE IN PEDIATRIC HEART TRANSPLANTATION F. Parisi, H. Danesi, C. Squitieri, L. Di Chiara, R.M. Di Donato, DMCCP - Transplant Unit, Bambino Ges’f9 Pediatric Hospital, Rome, Italy Introduction The efficacy of induction immunotherapy with antilymphocyte serum in reducing acute and chronic rejection has been demonstrated in children as well as adults. There are few data in the literature regarding the use of polyclonal ATGs in pediatric cardiac transplantation. We describe our single-center retrospective study on the use of Thymoglobuline in a pediatric population. Methods 31 consecutive heart tx recipients (mean age 7.8 yrs; median age 9 yrs; range: 4 m-17 yrs), who all survived surgery, were included in the study. Immunosuppression consisted of CyA (starting on day 0 and reaching a blood level of 250-300 ng/ml on day 7), Aza (2-3 mg/kg), steroids (tapered to obtain discontinuation after 1 mo). Thymoglobuline was given to all pts. as induction therapy at an age-dependent dose (1-1.5mg/kg/day between 0 and 1yr; 1.5-2 mg/kg/day 1 yr to 8 yrs; and 2.5 mg/kg/d ⬎8 yrs) and duration of treatment (1-7 days). In pts.⬍1 yr lymphocytes were maintained ⬎500/mm3. We evaluated the incidence of acute and chronic rejection, infections, PTLD, blood cell count and creatinine level over a mean follow-up of 3 yrs (range 1-7 yrs). Results 30 out of 31 pts are alive at the end of follow-up (1 death due to chronic rejection 28 mos after tx). During the first 3 months, 3 grade 3A and 10 grade 1A (Working Formulation grading system) rejection episodes occurred. All reversed after steroid treatment. Two pts, one of whom died, experienced chronic rejection. Creatinine was normal in all pts during follow-
Abstracts
cial correlates of smoking relapse were persistent or recurrent psychiatric distress (depression, anxiety) (r⫽.21) and caregiver (usually spouse) smoking (r⫽.21). Caregiver smoking was the only significant predictor of recipient relapse (B⫽.913. Smoking history is emerging as a significant health risk to organ txp recipients; risk of relapse is unknown. These findings underscore the need for further study of post-txp smokers and early intervention programs, involving not only recipients but also their caregivers. 75 ORTHOTOPIC TRANSPLANTATION FOR DEXTROCARDIA AND COMPLEX CONGENITAL HEART DISEASE J. Odim, J. Alejos, A. Alikhani, C. Burch, H. Laks, Surgery, University of California at Los Angeles, Los Angeles, CA Background: Despite steady progress in the results of children undergoing orthotopic heart transplantation, most series report better outcome in individuals with noncongenital cardiomyopathy. We sought to review our experience with this difficult subset of patients with complex congenital heart disease and dextrocardia. Methods: Seven children with dextrocardia have undergone 8 orthotopic heart transplants at our institution over the last 15 years. We retrospectively review their outcome. Results: Three boys and four girls each underwent transplantation at a mean age of 9.3 years (range, 3 to 16). The mean donor/recipient weight and height ratios were 1.08 (range,0.31 to 1.33) and 1.52 (range, 0.31 to 3.12) respectively. The mean donor ischemia time was 305 minutes (range, 255 to 390). Synthetic and biologic conduit material was used to preserve unobstructed systemic and pulmonary venous pathways. Immunosuppression consisted of CyA or Tacrolimus-based triple drug therapy (with azathioprine and prednisone). The mean number of rejection episodes per child was 0.7 (range, 0 to 2). No patient has developed systemic or pulmonary venous pathway obstruction. No patient has developed obstruction of the great vessels. One child required a pericardial window for a large effusion 3 weeks after transplantation. No patient has required further cardiac surgery or interventional cardiology. One patient required transplantation 3 years following the initial allograft because of coronary artery vasculopathy. There was one early and no late deaths at a mean follow-up period of 58 months (range,0.5 to 175). Conclusion: The usual levocardiac orientation of donor allografts makes orthotopic transplantation for endstage complex congenital heart disease and dextrocardia technically challenging. The early and intermediate term results in this subset of children are excellent and justify the clinical investment. Children with complex congenital heart defects, dextrocardia and anomalies of pulmonary and systemic venous relationships can undergo successful orthotopic heart transplantation. When end-stage heart failure supervenes, OHT should be considered a viable therapy. 76 BRONCHIAL ANASTOMOSIS COMPLICATIONS: COMPARISON BETWEEN PEDIATRIC LIVING DONOR DOUBLE LOBAR LUNG TRANSPLANT AND CADAVERIC DOUBLE LUNG RECIPIENTS J. Markley, W.J. Wells, M.V. Horn, V.A. Starnes, M.S. Woo, Cardiothoracic Surgery, Childrens Hospital Los Angeles, Los Angeles, CA
The Journal of Heart and Lung Transplantation January 2002 Pediatric living donor lobar lung transplant(LD) recipients receive lower lobes from 2 healthy adult donors. The size mismatch between the pediatric recipient to adult donor bronchi may increase the risk of anastomosis complications in LD recipients compared to cadaveric double lung (CL) transplant patients. We retrospectively reviewed all pediatric double lung transplant recipients who survived at least 1 year after surgery. All lung transplantation was performed by the same surgeon (VAS). All LD and 14/15 CL procedures were done with patients on cardiopulmonary bypass (CPB). Anastomosis complications were directly identified by bronchoscopy. 43 patients met inclusion criteria. 28 patients underwent LD transplant (12 males:16 females; mean age 14.7 ⫾ 3.6 years; 24 cystic fibrosis/4 pulmonary hypertension) and 15 patients had CL transplantation(7 males:8 females; mean age 13.0 ⫾ 6.1 years; 8 cystic fibrosis/2 pulmonary hypertension; 1 each with surfactant protein B deficiency, A-V malformation, non-transplant related obliterative bronchiolitis, idiopathic pulmonary fibrosis, and idiopathic pulmonary hemosiderosis). There was no significant difference in LD versus CL ages at time of transplant (p ⫽ 0.17, ns). A total of 6/43 (14%) patients had anastomosis complications. 2/28 (7%) LD patients had bronchial stenosis (right bronchial anastomosis) compared to 4/15 (27%) CL recipients (2 with right bronchial stenosis; 2 with bronchial stenosis bilaterally). LD mean ischemic time was significantly shorter than the CL ischemic times (79.3 ⫾ 21.8 minutes versus CL ischemic time of 193.3 ⫾ 66.0 minutes; p ⬍ 0.01). LD CPB time was 129.2 ⫾ 27.4 minutes versus CL CPB time of 112.9 ⫾ 37.9 minutes (p ⫽ 0.12, ns). None of the patients required revision of the anastomosis or stent placement. We conclude that pediatric LD recipients do not have a higher incidence of airway anastomosis complications compared to CL recipients. We speculate that transplant surgical experience, along with significantly lower ischemic time, reduces the risk of stenosis in pediatric LD recipients. 77 PULMONARY VENOUS DOPPLER PATTERNS IN PEDIATRIC CADAVERIC AND LIVING-DONOR LUNG TRANSPLANTATION A.M. Sharkey, M.C. Johnson, R. Hirsch, C.B. Huddleston, E.N. Mendeloff, 1Division of Pediatric Cardiology, Washington University, St Louis, MO; 2Pediatric Cardiothoracic Surgery, Washington University, St Louis, MO Purpose: Direct anastamosis of the pulmonary veins to the left atrium in living-donor lung transplantation (LDLT) may be more susceptible to torque or narrowing at suture lines than the cuff anastomosis of cadaveric lung transplantation (CLT). Perioperative TEE evaluation of these anastomotic sites is an important adjunct in the management of these patients. Methods: Perioperative TEE and pulmonary venous Doppler interrogations (VDI) were performed in 10 patients undergoing LDLT (mean age 14.3yr) and compared with 9 patients undergoing bilateral CLT (mean age 9.4yr). Perfusion scan and available cardiac catheterization data were also reviewed. Results: Peak flow velocities for both lungs were increased in patients following LDLT compared with CLT (L lung 157⫹/-29 vs 90⫹/-40 cm/sec; R lung 142⫹/-41 vs 79⫹/-22 cm/sec, p⬍0.01). There was no significant difference in VDI within LDLT or CLT. The VDI abnormalities and associated clinical course prompted cardiac catheterization in 4 patients (3 LDLT, 1 CLT). Three patients had balloon dilation of stenotic segmental veins, in all
The Journal of Heart and Lung Transplantation Volume 21, Number 1 cases pulmonary venous obstruction was accurately predicted by VDI on TEE. Conclusion: Pulmonary venous Doppler velocities are significantly increased in LDLT. VDI elevated beyond these ‘normal’ ranges should lead to a high index of suspicion for pulmonary vein stenosis. Elevated VDI, when associated with changing/ asymmetric perfusion imaging and protracted clinical course, should prompt further therapeutic interventions. 78 NON-INVASIVE DETECTION OF CORONARY ARTERY DISEASE BY DOBUTAMINE STRESS ECHOCARDIOGRAPHY IN CHILDREN AFTER HEART TRANSPLANTATION S. Di Filippo, M. Raboisson, F. Sassolas, A. Bozio, Pediatric Cardiology, Ho ˆpital Cardiologique Louis Pradel, Lyon, France Background: Coronary vasculopathy is the main cause cardiac graft failure. As yearly coronary angiography is invasive in children, a non-invasive method for detecting graft vasculopathy is needed. The aim of this study was to test Dobutamine-Stress Echocardiography (DSE) in a pediatric population, to assess its feasibility, safety and reliability in the detection of graft coronary artery disease. Methods: Eighteen patients, aged 2 days to 16.8 years at transplantation (mean 8.4 years) underwent 44 DSEs at a follow-up of 1.1 to 11.8 years (mean 5.1 years). Selective coronary angiography was performed for comparison. Echocardiographic recordings were obtained in 4 standard views of the left ventricle and measurements carried out within the frames of a 16-segment model. Segmental scores of contractility were obtained for each segment at each stage and a total segmental contractility index was calculated. Results: All patients reached the maximum dose-stage. No major complication occured. Maximum heart rate was 57% to 89% of predicted maximum. Maximum systolic blood pressure reached 190mmHg. Segmental scores were normal in 37 cases and abnormal in 7 cases. DSE results were concordant with angiography in 82% of the cases and discordant in 18% of the cases ( 4 negative DSEs with abnormal angiography and 2 positive DSEs with normal angiography) but there was no significant angiographic lesion with normal DSE. Conclusion: According to our study, DSE is a safe and easily feasible non-invasive method for detection of coronary vasculopathy in transplanted children. It seems to predict significant angiographic lesions but further larger studies are needed to demonstrate its reliability for detecting graft ischemia in children. 79 SEVERE OBLITERATIVE BRONCHIOLITIS IS ASSOCIATED WITH TRANSPLANT CORONARY ARTERY DISEASE IN PEDIATRIC HEART-LUNG RECIPIENTS P.D. Wearden,1 S.A. Webber,2 S.K. Gandhi,1 G.J. Boyle,2 Y.M. Law,2 S. Miller,2 P. Dickman,3 R.D. Siewers,1 F.A. Pigula,1 1 Cardiothoracic Surgery; 2Cardiology; 3Pathology, Children’s Hospital of Pittsburgh, Pittsburgh, PA Background: Acute rejection of the heart in the absence of concomitant lung rejection is thought to be uncommon in heartlung transplant (HLTx) recipients. The association between chronic rejection of the lung, obliterative bronchiolitis (OB) and
Abstracts
83
chronic rejection of the heart, transplant coronary artery disease (TxCAD), is less well known. Methods: A retrospective review of all patients undergoing HLTx at a single institution was performed. TxCAD was correlated with OB by histologic findings in autopsy and pathology specimens. Results: Thirty-six HLTxs were performed in 34 patients since 1985. Indications included congenital heart disease with pulmonary hypertension (17/34, 50%), primary pulmonary hypertension (14/34, 41%) and primary lung disease (3/34, 9%). The mean age at transplantation was 11.6 ⫾ 1 years and the mean follow-up period was 54 ⫾ 9 months. The Kaplan-Meier 1, 3 and 5 year survival was 71%, 62% and 43% respectively. Ten patients died in the perioperative period. One patient died from pneumonia one year following transplantation. Thirteen patients died as a result of complications from OB. No patient died as a direct result of cardiac rejection. There are 10 surviving patients. The freedom from OB at 1, 3 and 5 years was 79%, 48% and 32% and survival after the diagnosis of OB was 82%, 65% and 24% at the same time intervals. None of the patients experienced acute cardiac rejection. Of the 13 patients who died as a result of OB, 9 autopsies were available. All of these specimens demonstrated severe OB. The transplanted hearts were noted to have severe (3), moderate (3), mild (2) or no (1) TxCAD. Conclusions: In pediatric HLTx recipients, acute or chronic cardiac rejection was not found in the abscence of lung rejection; thus, surveillance heart biopsy is unwarranted. While OB is the cause of the greatest late mortality, moderate to severe TxCAD was found at autopsy in two-thirds of the specimens. This finding may have important implications when evaluating patients for repeat HLTx or double lung Tx following HLTx. 80 THYMOGLOBULINE威 USE IN PEDIATRIC HEART TRANSPLANTATION F. Parisi, H. Danesi, C. Squitieri, L. Di Chiara, R.M. Di Donato, DMCCP - Transplant Unit, Bambino Ges’f9 Pediatric Hospital, Rome, Italy Introduction The efficacy of induction immunotherapy with antilymphocyte serum in reducing acute and chronic rejection has been demonstrated in children as well as adults. There are few data in the literature regarding the use of polyclonal ATGs in pediatric cardiac transplantation. We describe our single-center retrospective study on the use of Thymoglobuline in a pediatric population. Methods 31 consecutive heart tx recipients (mean age 7.8 yrs; median age 9 yrs; range: 4 m-17 yrs), who all survived surgery, were included in the study. Immunosuppression consisted of CyA (starting on day 0 and reaching a blood level of 250-300 ng/ml on day 7), Aza (2-3 mg/kg), steroids (tapered to obtain discontinuation after 1 mo). Thymoglobuline was given to all pts. as induction therapy at an age-dependent dose (1-1.5mg/kg/day between 0 and 1yr; 1.5-2 mg/kg/day 1 yr to 8 yrs; and 2.5 mg/kg/d ⬎8 yrs) and duration of treatment (1-7 days). In pts.⬍1 yr lymphocytes were maintained ⬎500/mm3. We evaluated the incidence of acute and chronic rejection, infections, PTLD, blood cell count and creatinine level over a mean follow-up of 3 yrs (range 1-7 yrs). Results 30 out of 31 pts are alive at the end of follow-up (1 death due to chronic rejection 28 mos after tx). During the first 3 months, 3 grade 3A and 10 grade 1A (Working Formulation grading system) rejection episodes occurred. All reversed after steroid treatment. Two pts, one of whom died, experienced chronic rejection. Creatinine was normal in all pts during follow-