Pediatric transplantation
Competing Outcomes After Neonatal and Infant Wait-listing for Heart Transplantation

https://doi.org/10.1016/j.healun.2007.07.024Get rights and content

Background

Neonatal and infant heart transplantation is a therapeutic option for patients with end-stage cardiac lesions, yet infants continue to face a considerable shortage of donor organs. We sought to ascertain outcomes after listing for heart transplantation using a competing outcomes methodology, and to identify factors predicting each outcome.

Methods

Review of the Toronto cardiac transplant database was undertaken to identify infant patients (≤12 months) wait-listed for heart transplantation. Achievement of one of five possible outcomes was parametrically modeled, including: transplantation; death on the wait-list; delisting: too sick; delisting: clinically improved; and delisting for surgical palliation.

Results

Forty-three percent (117 of 269) of the total patient listings were infants (26 fetal/63 neonatal). Of the 117 patients, 80 (68%) underwent transplantation, 15 died on the wait-list, 9 were delisted (too sick/no longer eligible for transplant), 9 opted for surgical palliation and 4 were delisted (clinical improvement). Eighty-nine percent of outcomes were achieved by 3 months from listing. Blood group and transplant era predicted achieving transplantation. Factors predicting death on the wait-list included Canadian Status 4 (most urgent), and mechanical support. Status at listing also predicted delisting: too sick. Fetal listing predicted delisting for surgical alternative.

Conclusions

The first 3 months after listing are critical for achieving an outcome, particularly in higher status patients, affirming the need for timely organ replacement. Strategies such as ABO-incompatible transplantation continue to decrease wait-list mortality; however, these data demonstrate that blood type O and B patients continue to face longer wait-list duration. It is imperative that we continue to seek solutions for the shortage of infant donor organs in order to maximize the utility of heart transplantation as a therapeutic option.

Section snippets

Patient Population

Following institutional research ethics board approval we reviewed the cardiac and transplant databases at The Hospital for Sick Children to identify all infant patients assessed and wait-listed for heart transplantation. Patients were included if they were wait-listed for heart transplantation as a fetus, neonate (birth to <1 month) or infant (up to 12 months). At our institution, beginning in 1995, ABO-incompatible heart transplantation was utilized, with adoption as regular protocol in ∼1999

Results

Over the study duration there were 269 patient listings for heart transplant at our institution. Forty-three percent (117 of 269) of patients listed were infants (26 fetal/63 neonatal). Ten patients were “allosensitized” to donor HLA prior to transplant. ECMO was utilized pre-transplant in 18 patients (median duration 11 days, range 4 to 17 days), and a Berlin Heart in 1 patient. Table 1 presents patient characteristics of all babies wait-listed and included in the analysis.

Orthotopic de novo

Discussion

There was an observed trend over time toward shorter waiting times for heart transplantation in infants and a lower wait-list mortality than ever before. At 3 months after listing, 89% of patients had achieved an outcome, with 58% being transplanted and 13% dying on the wait-list. Interestingly, no additional patients died on the wait-list after this time-point, and no additional patients were delisted for surgical alternatives or because they were too sick. An additional 10 patients went on to

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    Copyright © 2007 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.