Andersons pediatric cardiology 1779
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FIG.67.13 Kaplan-Meiersurvivalinchildrenwithtransplantedheartsby
mechanicalcirculatorysupportusage.ECMO,Extracorporealmembrane
oxygenation;LVAD,leftventricularassistdevice;RVAD,rightventricular
assistdevice;TAH,totalartificalheart;VAD,ventricularassistdevice.
(FromtheregistryoftheInternationalSocietyofHeartandLung
Transplantation.JHeartLungTransplant.2016;35(10):1185–1195.)
RiskFactorsforDeath
Theriskfactorsfordeathinthefirstyearfollowinghearttransplantationduring
childhoodareoutlinedinTable67.1.Theyincludeadiagnosisofcongenital
heartdisease,needfordialysisorextracorporealmechanicalsupport,mechanical
ventilationbeforetransplantation,infection,andretransplantation.Continuous
variablesthatincurriskincludeischemictime,donorweight,estimated
glomerularfiltrationrate,andpediatriccentervolume.2Owingtothelongevity
oftheregistry,riskfactorsformortalityat5,10,and15yearscannowbe
determinedinalargenumberofchildhoodhearttransplantpatientsandare
summarizedinTable67.2.2DatafromthePHTSwereusedtoidentify
pretransplantfactorsbycardiacdiagnosis(cardiomyopathyvs.congenitalheart
disease)tomodelrisksofgraftloss.10Riskfactorscommontobothdiagnostic
groupsincludedmarkersofrenalfunctionandelevatedpanelreactiveantibodies
(PRAs,seefurtheron).Independentriskfactorsforpatientswithcongenital
heartdiseaseonlyincludedventilatordependencyandlowrecipientbody
surfacearea.Theresultantriskpredictionmodelforcardiomyopathyperformed
well,butthatforcongenitalheartdiseasehadlimitedabilitytopredictoutcomes.
Table67.1
CategoricRiskFactorsfor1-YearMortalityinChildrenAfterHeart
Transplantation(N=5646)
RiskFactor
InfectionrequiringIVdrugtherapywithin2weeksofTx
Ventilator
Donorcauseofdeath:cerebrovascularvs.trauma
Diagnosis:CHDvs.DCM
Diagnosis:ReTxvs.DCM
Recipientdialysis
ECMO:ECMO/CHDvs.noECMO
N
681
826
396
1979
304
146
145
HazardRatio(95%CI)
1.36(1.10–1.68)
1.41(1.1.3–1.76)
1.59(1.20–2.09)
1.91(1.46–2.52)
2.23(1.53–3.25)
2.36(1.57–3.57)
2.42(2.42–3.35)
Pvalue
.005
.002
.001
<.0001
<.0001
<.0001
<.0001
CHD,Congenitalheartdisease;CI,confidenceinterval;DCM,dilatedcardiomyopathy;ECMO;
extracorporealmembraneoxygenation;Tx,transplant;ReTx,retransplant.
DatafromtheregistryoftheInternationalSocietyofHeartandLungTransplantation.JHeart
LungTransplant.2016;35(10):1185–1195.
Table67.2
CategoricRiskFactorsfor1-,5-,10-,and15-YearMortalityin
ChildrenAfterHeartTransplantation
TimePosttransplant
Diagnosis:DCMvs.CHD
Diagnosis:CHDvs.DCM
Diagnosis:retransplantationvs.DCM
Diagnosis/device:VAD/notCHDvs.nodevice
Diagnosis/device:ECMO/notCHDvs.nodevice
Diagnosis/device:ECMO/CHDvs.nodevice
Diagnosis/device:ECMOvs.nodevice
Diagnosis/device:CHD/nodevicevs.DCM/no
device
Diagnosis/device:CHD/ECMOvs.DCM/no
device
Diagnosis/device:CHD/MCSDvs.DCM/no
device
MODELa
1YearbyRecipientAgeGroup
<1
1–5
6–10
11–17
Year Years
Years
Years
0.338
1.88
1.963
1.943
2.155
2.563
3.521
5
10
Year Year
15
Year
1.595 1.390 1.145
1.822 1.496 1.634
1.956
1.363
2.267
3.042
7.614
InfectionrequiringIVdrugtherapy(within2
weeksofTx)
Recipienttransfusions
Ventilator
Recipientdialysis
Pre-Txcerebrovascularevent
MostrecentPRA10+%
Recipientsteroids
DonorCMV+/recipientCMV–vs.not
mismatched
Donorclinicalinfection
Donorcauseofdeath:cerebrovascularvs.head
trauma
TRANSPLANTERA
1995–96vs.1989–90
1996–97vs.1994–95
1997–98vs.1989–90
1998–99vs.1994–95
2000–01vs.1994–95
2002–04vs.1994–95
2007–09vs.1999–2000
Maledonor/femalerecipientvs.maledonor/male
recipient
Femaledonor/femalerecipientvs.male
donor/malerecipient
1.438
1.268
1.854
1.766
2.842
1.820
4.60
1.270
1.665
1.176
0.466
1.287 1.394
1.278
0.604
0.577
1.941
0.797
0.841
0.690
0.842
0.753
0.698
0.752
1.430 1.238
1.250
a1year:January1,2003toDecember31,2013;5years:January1,1999toDecember31,2009;
10years:January1,1994toDecember31,2004;15years:January1,1989toDecember31,
1999.
CHD,Congenitalheartdisease;CMV,cytomegalovirus;DCM,dilatedcardiomyopathy;ECMO,
extracorporealmembraneoxygenation;IV,intravenous;MCSD,mechanicalcirculatorysupport
device;PRA,panelreactiveantibody;Tx,transplant;VAD,ventricularassistdevice.
DatafromtheregistryoftheInternationalSocietyofHeartandLungTransplantation.JHeart
LungTransplant.2016;35(10):1185–1195.
Posttransplantfactorsassociatedwithgraftlossanddeathincludecardiac
allograftvasculopathy(CAV),11,12rejection,13,14posttransplant
lymphoproliferativedisorder(PTLD),15,16andinfection(seelater);inaddition,
attemptshavebeenmadetodeviseandvalidatearisk-predictionmodelto
predictgraftloss.17
CausesofDeath
ThecausesofdeathreportedtotheISHLTregistry,stratifiedbytime
posttransplant,aresummarizedinTable67.3.2Rejection,infection,primary
graftfailure,andsuddencardiacdeatharethemajorcausesofdeathinchildren
withinthefirst5years.Allograftvasculopathyaccountedforaboutseven-tenths
