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21 Risk Factors for and Risk of Graft Loss after Pediatric Heart Retransplantation: Analysis of the ISHLT Registry
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The Journal of Heart and Lung Transplantation, Vol 31, No 4S, April 2012
exacerbate the OB histopathology seen in lung allografts subjected to GER-associated chronic aspiration. This study suggests that ischemia and aspiration work synergistically, possibly through innate immune pathways, to increase the development of OB. 19 Pediatric Heart Transplantation from Donors with Depressed Ventricular Function: An Analysis of the United Network of Organ Sharing Database J.W. Rossano,1 K.Y. Lin,1 S.M. Paridon,1 J.W. Gaynor,2 R.E. Shaddy,1 B.D. Kaufman.1 1Cardiology, The Children’s Hospital of Philadelphia/ University of Pennsylvania, Philadelphia, PA; 2Cardiothoracic Surgery, The Children’s Hospital of Philadelphia/University of Pennsylvania, Philadelphia, PA. Purpose: Waitlist mortality for children remains high. Potential donor hearts with depressed ventricular function are often declined. The purpose of our study was to assess if pediatric heart transplant (HT) recipients of grafts with depressed left ventricular ejection fraction (LVEF) would have comparable survival to those with normal LVEF. Methods and Materials: Retrospective study of the United Network of Organ Sharing Database for pediatric HTs from 10/26/1999 to 06/30/2011. Patients (pts) were grouped based on donor LVEF: normal (LVEF ⱖ 55%), mildly depressed (LVEF 45-54%), or moderate to severely depressed (LVEF ⬍ 45). The primary outcome was graft survival. Results: During the study period there were 3,672 pediatric HTs; 3,306 (90%) had a LVEF reported. LVEF was mildly depressed in 245 (7%) and moderately to severely depressed in 172 (5%). Pts receiving grafts with moderately to severely depressed LVEF were younger and weighed less (p⬍0.001 for both) than those receiving grafts with higher LVEF. Donors with depressed LVEF were more likely to be on inotropes (p⫽0.04), but the recipient use of inotropes (p⫽0.94), mechanical ventilation (p⫽0.49), and extracorporeal membrane oxygenation (p⫽0.41) did not differ between LVEF groups. Thirty day, 6 month, 1 and 5 year (yr) graft survival was similar among donor LVEF groups. Median graft survival from donors with normal LVEF (10.6 yrs) was similar to survival from donors with mildly depressed LVEF (9.7 yrs, p⫽0.24), and from donors with moderately to severely depressed LVEF (9.1 yrs, p⫽0.13). On multivariable analysis, moderately to severely depressed LVEF (HR 1.18, 95% CI 0.91-1.54) and mildly depressed LVEF (HR 1.23, 95% CI 0.97-1.57) had similar survival compared to normal LVEF. Conclusions: Use of donors with depressed LVEF is uncommon in pediatric HTs (⬍15%), yet graft survival does not significantly differ from donors with normal LVEF. Hearts from donors with depressed LVEF should be considered in selected pediatric HT pts. 20 The Effect of Oversizing Donor Cardiac Allografts on In-Hospital Outcomes in Pediatric Heart Transplant Recipients E.D. McFeely,1 R.K. Singh,2 M.E. Richmond,2 W.A. Zuckerman,2 T.M. Lee,2 L. Gilmore,2 R. Rodriguez,2 J.M. Chen,3 L.J. Addonizio.2 1 Columbia University College of Physicians and Surgeons, New York, NY; 2Pediatric Cardiology, Columbia University Medical Center, New York, NY; 3Pediatric Cardiothoracic Surgery, Columbia University Medical Center, New York, NY. Purpose: Prior studies have shown no difference in survival in pediatric heart transplant (HT) recipients with “undersized” (donor-recipient weight ratio% (WR%)⬍80%) or “oversized” (WR%⬎120%) donor hearts. Our institution commonly accepts “significantly oversized” donor hearts (WR%⬎200%). We evaluated clinical parameters, in-hospital outcomes and survival for pediatric HT recipients receiving significantly oversized heart allografts. Methods and Materials: 184 pediatric HT patients (ages 0-22 years) at our institution from 2000-2011 were divided into 2 groups: control (WR%⫽80-200%, n⫽165) and significantly oversized (WR%⬎200%, n⫽19, range WR%⫽208-338%). A chart review for donor/recipient characteristics and in-hospital outcomes was performed for both groups. Data analysis included chi-square, t-tests, survival curves, and multivariate Cox proportional hazard ratios.
Results: The significantly oversized group had a female predominance (74% vs. 44%, p⫽0.015), smaller BSA (0.79 m2 vs. 0.94 m2, p⫽0.018), and higher incidence of UNOS status 1A listing (100% vs. 80%, p⫽0.027) and pre-operative ventilator use (32% vs. 12%, p⫽0.033) as compared to the control group. There was no difference in post-operative atelectasis on chest X-ray (p⫽0.61), delayed sternal closure (p⫽0.59), or hypertension (p⫽0.81). Kaplan-Meier survival curves were not different between groups (p⫽0.53). Multivariable analysis demonstrated that both groups had similar post-operative intubation time (HR⫽0.86, 95% CI⫽0.51-1.43, p⫽0.56), hospital LOS (HR⫽0.94, 95% CI⫽0.56-1.58, p⫽0.82), and survival (HR⫽0.93, 95% CI⫽0.32-2.74, p⫽0.9) when controlling for age, severity of illness, and cardiac diagnosis. Conclusions: Post-operative outcomes such as length of intubation, hospital LOS and survival in pediatric HT recipients are not adversely affected by the use of significantly oversized donor allografts. Pediatric patients needing heart transplantation should regularly be listed for donor hearts with WR% greater than 200%. 21 Risk Factors for and Risk of Graft Loss after Pediatric Heart Retransplantation: Analysis of the ISHLT Registry J. Conway,1 L.B. Edwards,2 R. Kirk,3 B. McCrindle,1 C. Manlhiot,1 A.I. Dipchand.1 1Labatt Family Heart Center, The Hospital for Sick Children, Toronto, ON, Canada; 2International Society of Heart and Lung Transplant Registry, Addison, TX; 3Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom. Purpose: Heart transplantation (Tx) has become the standard of care for many children with life-threatening cardiac conditions. While the indications for primary transplantation (PTx) are generally agreed upon, the role of retransplantation has remained controversial. We sought to explore the risk factors for retransplantation and long term outcomes. Methods and Materials: Data from the ISHLT Transplant Registry was used to examine the above aims in patients who had a PTx at ⱕ 18 years of age. Results: A total of 9,883 Tx between 1998-2009 were reviewed. Of these 9,235 (93.4%) were PTx, 617 (6.2%) were 1st retransplant and 31 (0.3%) were 2nd or 3rd retransplants. Median age at retransplant was 14 years (IQR:8-18, 5th-95th:1-26 yrs). In multivariable survival regression models, factors associated with retransplant in the 1st post-Tx year included: ventilation prior to PTx (HR:2.4,p⫽0.001), older donor age (HR: 1.02,p⫽0.01), need for pre-discharge AICD (HR:3.4,p⫽0.04) or reoperation prior to discharge (HR:8.8,p⬍0.001). Risk factors associated with retransplant ⬎1 year after PTx included: higher pre-Tx PRA (HR:1.012 per 1% increase,p⬍0.001), restrictive cardiomyopathy (HR:1.6,p⫽0.03) and donor group A (HR: 1.3,p⫽0.05). 10-yr mortality after retransplantation was higher than PTx (54% vs 40%,HR:1.4,p⬍0.001);similarly 10-yr risk of 2nd or 3rd retransplant was also higher after 1st retransplant than after PTx (16% vs. 9%,HR:1.7,p⫽0.001). Patients retransplanted for primary graft failure had decreased 10-yr survival compared to those with graft vasculopathy (38% vs. 45%,HR:1.5,p⫽0.003) but no differences were observed in risk of requiring a second retransplant (86% vs. 87% freedom at 10-yrs, HR:1.0,p⫽0.93). Conclusions: In this, the largest analysis of pediatric retransplant patients, risk factors not previously recognized for retransplantation were identified, such as the need for an AICD prior to discharge, and previously identified factors were confirmed. Long-term survival in this cohort of patients continues to be reduced in comparison with PTx.
22 Is Lung Transplantation Survival Better in Infants? Analysis of over 80 Infants M.S. Khan,1 J.S. Heinle,1 I. Adachi,1 B. Shirkey,2 M.G. Schecter,3 G.B. Mallory,3 D.L.S. Morales.1 1Congenital Heart Surgery, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX; 2 Congenital Heart Surgery, Texas Children’s Hospital, Houston, TX; 3 Pulmonology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX.
The Journal of Heart and Lung Transplantation, Vol 31, No 4S, April 2012
exacerbate the OB histopathology seen in lung allografts subjected to GER-associated chronic aspiration. This study suggests that ischemia and aspiration work synergistically, possibly through innate immune pathways, to increase the development of OB. 19 Pediatric Heart Transplantation from Donors with Depressed Ventricular Function: An Analysis of the United Network of Organ Sharing Database J.W. Rossano,1 K.Y. Lin,1 S.M. Paridon,1 J.W. Gaynor,2 R.E. Shaddy,1 B.D. Kaufman.1 1Cardiology, The Children’s Hospital of Philadelphia/ University of Pennsylvania, Philadelphia, PA; 2Cardiothoracic Surgery, The Children’s Hospital of Philadelphia/University of Pennsylvania, Philadelphia, PA. Purpose: Waitlist mortality for children remains high. Potential donor hearts with depressed ventricular function are often declined. The purpose of our study was to assess if pediatric heart transplant (HT) recipients of grafts with depressed left ventricular ejection fraction (LVEF) would have comparable survival to those with normal LVEF. Methods and Materials: Retrospective study of the United Network of Organ Sharing Database for pediatric HTs from 10/26/1999 to 06/30/2011. Patients (pts) were grouped based on donor LVEF: normal (LVEF ⱖ 55%), mildly depressed (LVEF 45-54%), or moderate to severely depressed (LVEF ⬍ 45). The primary outcome was graft survival. Results: During the study period there were 3,672 pediatric HTs; 3,306 (90%) had a LVEF reported. LVEF was mildly depressed in 245 (7%) and moderately to severely depressed in 172 (5%). Pts receiving grafts with moderately to severely depressed LVEF were younger and weighed less (p⬍0.001 for both) than those receiving grafts with higher LVEF. Donors with depressed LVEF were more likely to be on inotropes (p⫽0.04), but the recipient use of inotropes (p⫽0.94), mechanical ventilation (p⫽0.49), and extracorporeal membrane oxygenation (p⫽0.41) did not differ between LVEF groups. Thirty day, 6 month, 1 and 5 year (yr) graft survival was similar among donor LVEF groups. Median graft survival from donors with normal LVEF (10.6 yrs) was similar to survival from donors with mildly depressed LVEF (9.7 yrs, p⫽0.24), and from donors with moderately to severely depressed LVEF (9.1 yrs, p⫽0.13). On multivariable analysis, moderately to severely depressed LVEF (HR 1.18, 95% CI 0.91-1.54) and mildly depressed LVEF (HR 1.23, 95% CI 0.97-1.57) had similar survival compared to normal LVEF. Conclusions: Use of donors with depressed LVEF is uncommon in pediatric HTs (⬍15%), yet graft survival does not significantly differ from donors with normal LVEF. Hearts from donors with depressed LVEF should be considered in selected pediatric HT pts. 20 The Effect of Oversizing Donor Cardiac Allografts on In-Hospital Outcomes in Pediatric Heart Transplant Recipients E.D. McFeely,1 R.K. Singh,2 M.E. Richmond,2 W.A. Zuckerman,2 T.M. Lee,2 L. Gilmore,2 R. Rodriguez,2 J.M. Chen,3 L.J. Addonizio.2 1 Columbia University College of Physicians and Surgeons, New York, NY; 2Pediatric Cardiology, Columbia University Medical Center, New York, NY; 3Pediatric Cardiothoracic Surgery, Columbia University Medical Center, New York, NY. Purpose: Prior studies have shown no difference in survival in pediatric heart transplant (HT) recipients with “undersized” (donor-recipient weight ratio% (WR%)⬍80%) or “oversized” (WR%⬎120%) donor hearts. Our institution commonly accepts “significantly oversized” donor hearts (WR%⬎200%). We evaluated clinical parameters, in-hospital outcomes and survival for pediatric HT recipients receiving significantly oversized heart allografts. Methods and Materials: 184 pediatric HT patients (ages 0-22 years) at our institution from 2000-2011 were divided into 2 groups: control (WR%⫽80-200%, n⫽165) and significantly oversized (WR%⬎200%, n⫽19, range WR%⫽208-338%). A chart review for donor/recipient characteristics and in-hospital outcomes was performed for both groups. Data analysis included chi-square, t-tests, survival curves, and multivariate Cox proportional hazard ratios.
Results: The significantly oversized group had a female predominance (74% vs. 44%, p⫽0.015), smaller BSA (0.79 m2 vs. 0.94 m2, p⫽0.018), and higher incidence of UNOS status 1A listing (100% vs. 80%, p⫽0.027) and pre-operative ventilator use (32% vs. 12%, p⫽0.033) as compared to the control group. There was no difference in post-operative atelectasis on chest X-ray (p⫽0.61), delayed sternal closure (p⫽0.59), or hypertension (p⫽0.81). Kaplan-Meier survival curves were not different between groups (p⫽0.53). Multivariable analysis demonstrated that both groups had similar post-operative intubation time (HR⫽0.86, 95% CI⫽0.51-1.43, p⫽0.56), hospital LOS (HR⫽0.94, 95% CI⫽0.56-1.58, p⫽0.82), and survival (HR⫽0.93, 95% CI⫽0.32-2.74, p⫽0.9) when controlling for age, severity of illness, and cardiac diagnosis. Conclusions: Post-operative outcomes such as length of intubation, hospital LOS and survival in pediatric HT recipients are not adversely affected by the use of significantly oversized donor allografts. Pediatric patients needing heart transplantation should regularly be listed for donor hearts with WR% greater than 200%. 21 Risk Factors for and Risk of Graft Loss after Pediatric Heart Retransplantation: Analysis of the ISHLT Registry J. Conway,1 L.B. Edwards,2 R. Kirk,3 B. McCrindle,1 C. Manlhiot,1 A.I. Dipchand.1 1Labatt Family Heart Center, The Hospital for Sick Children, Toronto, ON, Canada; 2International Society of Heart and Lung Transplant Registry, Addison, TX; 3Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom. Purpose: Heart transplantation (Tx) has become the standard of care for many children with life-threatening cardiac conditions. While the indications for primary transplantation (PTx) are generally agreed upon, the role of retransplantation has remained controversial. We sought to explore the risk factors for retransplantation and long term outcomes. Methods and Materials: Data from the ISHLT Transplant Registry was used to examine the above aims in patients who had a PTx at ⱕ 18 years of age. Results: A total of 9,883 Tx between 1998-2009 were reviewed. Of these 9,235 (93.4%) were PTx, 617 (6.2%) were 1st retransplant and 31 (0.3%) were 2nd or 3rd retransplants. Median age at retransplant was 14 years (IQR:8-18, 5th-95th:1-26 yrs). In multivariable survival regression models, factors associated with retransplant in the 1st post-Tx year included: ventilation prior to PTx (HR:2.4,p⫽0.001), older donor age (HR: 1.02,p⫽0.01), need for pre-discharge AICD (HR:3.4,p⫽0.04) or reoperation prior to discharge (HR:8.8,p⬍0.001). Risk factors associated with retransplant ⬎1 year after PTx included: higher pre-Tx PRA (HR:1.012 per 1% increase,p⬍0.001), restrictive cardiomyopathy (HR:1.6,p⫽0.03) and donor group A (HR: 1.3,p⫽0.05). 10-yr mortality after retransplantation was higher than PTx (54% vs 40%,HR:1.4,p⬍0.001);similarly 10-yr risk of 2nd or 3rd retransplant was also higher after 1st retransplant than after PTx (16% vs. 9%,HR:1.7,p⫽0.001). Patients retransplanted for primary graft failure had decreased 10-yr survival compared to those with graft vasculopathy (38% vs. 45%,HR:1.5,p⫽0.003) but no differences were observed in risk of requiring a second retransplant (86% vs. 87% freedom at 10-yrs, HR:1.0,p⫽0.93). Conclusions: In this, the largest analysis of pediatric retransplant patients, risk factors not previously recognized for retransplantation were identified, such as the need for an AICD prior to discharge, and previously identified factors were confirmed. Long-term survival in this cohort of patients continues to be reduced in comparison with PTx.
22 Is Lung Transplantation Survival Better in Infants? Analysis of over 80 Infants M.S. Khan,1 J.S. Heinle,1 I. Adachi,1 B. Shirkey,2 M.G. Schecter,3 G.B. Mallory,3 D.L.S. Morales.1 1Congenital Heart Surgery, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX; 2 Congenital Heart Surgery, Texas Children’s Hospital, Houston, TX; 3 Pulmonology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX.