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Update on Pediatric Cardiac Transplantation

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Update on Pediatric Cardiac Transplantation Dr Jameel Al-ata Consultant & Assistant Professor of Pediatrics & Pediatric Cardiology Taif April 2007 – PowerPoint PPT presentation

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Title: Update on Pediatric Cardiac Transplantation


1
Update on Pediatric Cardiac Transplantation
  • Dr Jameel Al-ata
  • Consultant Assistant Professor of Pediatrics
    Pediatric Cardiology
  • Taif April 2007

2
Introduction
  • Orthotopic pediatric heart transplantation is
    well established for infants children with
    severe forms of CHD or cardiomyopathies.
  • The one month , 1 y , 5 y , 10 y survival rate
    is 90 , 85 , 75 , 65 respective

3
Indication
  • Heart transplant is indicated when life
    expectancy is less than 1-2 y. OR unacceptable
    quality of sec to End-stage heart disease.
  • CMP , CHD with ventricular failure are primary
    indications.
  • HLHS , HIV , hepatitis are controversial
    indications.

4
DIAGNOSIS IN PEDIATRIC HEART TRANSPLANT
RECIPIENTS (Age lt 1 Year)
1988-1995
1/1996-6/2005
J Heart Lung Transplant 200625893-903
5
DIAGNOSIS IN PEDIATRIC HEART TRANSPLANT
RECIPIENTS (Age 1-10 Years)
6
DIAGNOSIS IN PEDIATRIC HEART TRANSPLANT
RECIPIENTS (Age 11-17 Years)
7
Pre-transplant considerations
8
Pre-transplant medical considerations
  • Malnutrition growth failure are common
    (anorexia , vomiting , mal-absorption ,
    hyper-metabolic state).
  • Co-morbid conditions like PLE , renal chronic
    liver disease may be contributing to the poor
    nutritional state.

9
Immunization
  • Prior to transplantation Immunization records
    must be reviewed and vaccines given according to
    recommendations.
  • Influenza vaccination should be yearly.
  • Measles varicella vaccine should be given( if
    not immune ) titers checked 6-8 weeks.
  • Hepatitis,B vaccine should also be given.
  • Pneumococcal vaccine is recommended even over 2
    years of age.

10
Waiting list
  • Waiting time varies according to case severity ,
    blood type , recipient body WT.
  • In the U.S. organ procurement transplantation
    network 2001 annual report the median time to
    transplantation for a 4 year old was 191 days
    when listed with 84 same age range. ( 190 days
    for less than 1 year old listed with 142 patients)

11
Pre-transplant Surgical considerations
  • Nearly 50 of refered cases are Coronary Heart
    Disease most of which undergone multiple
    palliations.
  • In experienced centers , even those with
    pulmonary arteries stenosis , anomalies of system
    pulmonary venous drainage or atrial
    arrangement abnormalities have nearly comparable
    survival to cardiomyopathies.

12
Surgical considerations
  • High output failure may be sec to failure to
    recognize important aorto-pulmonary collateral
    circulation in transplanted cyanotic CHD patient.
  • PLE , ch liver disease pulmonary. AVMs poses
    additional premorbid challenges to the failed
    fontan transplantation patient.
  • Results of transplantation for ACHD are poor
    ( unclear reasons ).

13
Surgical condition
  • PVR less than 10 woods units is acceptable , but
    poses increased risk of acute RV failure (
    compared to less than 6 ).
  • ECMO can be used to bridge infants and small
    children ( not more than 2 wks because of
    increased risk of complications ).
  • Ventricular assist devices can a successfull
    bridge for the older child.

14
AGE DISTRIBUTION OF PEDIATRIC HEART RECIPIENTS
(Transplants January 1996 - June 2005)
Number of Transplants
ISHLT
2006

J Heart Lung Transplant 200625893-903
15
Survival after Pediatric Heart Transplantation
  • 10 y actuarial survival rate between 1982 2001
    more than 50 ( ISHLT report ).
  • Infants have higher mortality in first few months
    , with better outcome if they survive the 1st
    year.
  • Adolescents have annual survival decrement rate
    of 4

16
PEDIATRIC HEART TRANSPLANTATION Kaplan-Meier
Survival (1/1982-6/2004)
J Heart Lung Transplant 200625893-903
17
PEDIATRIC HEART TRANSPLANTATION Kaplan-Meier
Survival by Era (1/1982-6/2004)
J Heart Lung Transplant 200625893-903
18
Risk Factors
19
PEDIATRIC HEART TRANSPLANTS (1/1995-6/2004) Risk
Factors For 1 Year Mortality
J Heart Lung Transplant 200625893-903
20
PEDIATRIC HEART TRANSPLANTS (1/1995-6/2004) Border
line Significant Risk Factors For 1 Year Mortality
J Heart Lung Transplant 200625893-903
21
PEDIATRIC HEART TRANSPLANTS (1/1995-6/2004)
Factors Not Significant for 1 Year Mortality
  • Recipient Factors
  • IV inotropes, sternotomy, thoracotomy, history of
    malignancy, height, recent infection, age, PA
    pressure, cardiac output, pulmonary vascular
    resistance.

22
PEDIATRIC HEART TRANSPLANTS (1/1995-6/2004)
Factors Not Significant for 1 Year Mortality
  • Donor Factors
  • Gender, history of hypertension, height, clinical
    infection, history of diabetes
  • Transplant Factors
  • CMV mismatch, ABO identical/compatible, ischemia
    time, HLA mismatch, transplant center volume

23
PEDIATRIC HEART TRANSPLANTS (1/1995-6/2000) Risk
Factors For 5 Year Mortality Conditional on 1
Year Survival
24
PEDIATRIC HEART TRANSPLANTS (1/1995-6/2000)
Factors Not Significant for Conditional 5 Year
Mortality
  • Recipient Factors
  • History of malignancy, recent infection,
    hospitalized at time of transplant, bilirubin,
    creatinine, cardiac output, pulmonary vascular
    resistance, PRA, sternotomy, ventilator, VAD,
    age, PA pressures

25
PEDIATRIC HEART TRANSPLANTS (1/1995-6/2000)
Factors Not Significant for Conditional 5 Year
Mortality
  • Donor Factors
  • Cause of death, history of hypertension, weight,
    height, age, gender, clinical infection at
    donation
  • Transplant Factors
  • Donor/recipient weight ratio, year of transplant,
    CMV mismatch, transplant center volume, induction
    use, treated for infection prior to discharge,
    dialysis prior to discharge

26
Long term management post Pediatric Heart
Transplantation
27
PEDIATRIC HEART RECIPIENTS Functional Status of
Surviving Recipients (Follow-ups April 1994 -
June 2005)
J Heart Lung Transplant 200625893-903
28
Early issues
  • Immunosuppressive therapy needed for life of the
    graft.
  • To prevent host immune response to donor antigens
    minimize toxicity
  • ( nephrotoxicity , bone marrow suppression ,
    hyperlipidemia , diabetes ..etc ).

29
Immunosuppressive agents
  • Triple protocol ( calcineurin inhibitro e.g.
    cyclosporine or tacrolimus plus MMF ( replacing
    azathiop ) and steroids ( weaned within 1st year
    ).
  • Rapamycin as rescue therapy for acute rejection.

30
PEDIATRIC HEART RECIPIENTS Induction
Immunosuppression (Transplants January 2001 -
June 2005)
J Heart Lung Transplant 200625893-903
31
PEDIATRIC HEART RECIPIENTS Maintenance
Immunosuppression at Time of Follow-up (Follow-ups
January 2001 - June 2005)
J Heart Lung Transplant 200625893-903
32
Morbidity
33
POST-HEART TRANSPLANT MORBIDITY FOR PEDIATRICS
Cumulative Prevalence in Survivors within 1 Year
Post-Transplant (Follow-ups April 1994 - June
2005)
34
POST-HEART TRANSPLANT MORBIDITY FOR PEDIATRICS
Cumulative Prevalence in Survivors within 5
Years Post-Transplant (Follow-ups April 1994 -
June 2005)
35
POST-HEART TRANSPLANT MORBIDITY FOR PEDIATRICS
Cumulative Prevalence in Survivors within 8
Years Post-Transplant (Follow-ups April 1994 -
June 2005)
36
FREEDOM FROM CORONARY ARTERY VASCULOPATHY For
Pediatric Heart Recipients (Follow-ups April
1994 - June 2005)
37
Renal Dysfunction Sys Hypertension
  • 73 n. renal function at 5 y
  • Factors for decreased renal function include low
    COP, ischemia/ repefusion calcineurin
    inhibitant.
  • 2/5 have decreased glomerular filtration at long
    term follow up.
  • Aggressive high blood pressure therapy and use of
    non nephrotoxic agents ( mmf ) promotes renal
    function preservation
  • A small number may need renal transplant
  • 60 at 5 y will need at least 1 antihypertensive

38
FREEDOM FROM SEVERE RENAL DYSFUNCTION For
Pediatric Heart Recipients (Follow-ups April
1994 - June 2005)
39
Rejection
  • 2 /3 recipients are free at 1 m. , but lt 1/3 at 1
    year.
  • Risk factors include older age at transplant ,
    af-am race CMV previous rejection.
  • Usually no symptoms.
  • Mild to moderate rejection DX. At surv.
    Endomyocardial biopsies.

40
S S of rejection
  • Fatigue , decreased appetite,nausea,abdominal
    pain, rapid including in weight., fussiness
    poor feeding.
  • Tachycardia, irregular rhythm,fever,gallop
    hepatomegally.

41
Chronic rejection( graft vasculopathy)
  • Accelerated coronary vasculopathy is the leading
    cause of death in late survivors.
  • Is due to myointimal prolifration involving the
    entire vessel including intra myo.branch
  • Angiography is not sensitive for mild forms.
  • 75 overall prevalence by IVUS. AT 5 Y.
  • Ectopy, pre-syncope, syncope, interm oedema, ex
    intolerance rarely chest pain are some
    symptoms.
  • Rapamycin prevents it in animals.

42
Cause of Death
  • Acute allograft failure 1st 30 days
  • Acute cellular rejection infections 1-5 y
  • Chronic rejection causing heart or pt. Loss
    beyond 5 y.

43
Other issues
  • Growth
  • Osteoporosis
  • Exercise
  • Psychosocial
  • Noncompliance

44
Summary
  • Pediatric heart transplantation is effective
  • Multidisciplinary approach is needed
  • Vasculopathy is a major obstacle
  • Much needed in KSA.

45
THANK YOU
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