In a study presented at the 50th Annual Meeting of the Society of Thoracic Surgeons, many infants and children who underwent heart transplantation have survived for more than 15 years, with good cardiac function and reasonable quality of life.
Hannah Copeland, MD, and colleagues at Loma Linda University in California conducted a retrospective chart review of 337 pediatric heart transplantation recipients who received new hearts between 1985 and 1998. Median follow-up was 20.2 years.
Of those recipients, 183 (115 males) survived at least 15 years, Copeland said at a press conference. Median age at transplant was 56 days (range, 0 days to 17.48 years) and median time from listing to transplant was 20 days (range, 0-182).
Of those who survived at least 15 years, 151 are currently alive and had good cardiac function. The mean left ventricular ejection fraction in this group was 62%, according to Copeland. Eighty-two patients are still alive 20 to 25 years after transplant and seven are still alive more than 25 years after transplant, she said.
Copeland also presented data on immunotherapy regimens for the 151 patients who are currently alive. Twenty-five are on monotherapy, 87 on dual therapy, 24 on triple therapy, five on quadruple therapy and 10 are on an unknown regimen. Most patients on monotherapy are taking cyclosporine or tacrolimus, and 119 of the 151 patients are on a steroid-free regimen.
Acceptable long-term survival
“Pediatric heart transplantation provides acceptable long-term survival beyond 15 years,” Copeland said.
Acute renal dysfunction after transplant occurred in 38 patients, and 25 eventually required chronic dialysis. Of the 25 who required dialysis, the condition resolved in four patients, 10 died, nine required renal transplant and two remain on dialysis, according to data presented.
Seventeen of the patients (median age, 16.4 years) required renal transplant after heart transplant, Copeland said. The median time between cardiac transplant and renal transplant was 15.5 years. Survival after renal transplant was 100% at 1 year and 92.3% at 5 years.
Thirty-six patients required a second heart transplant, 30 because of graft vasculopathy and six because of graft failure. Four patients required a third transplant, all for graft vasculopathy, according to Copeland.
The causes of death for the 32 patients who survived for at least 15 years but subsequently died were as follows: 11 from graft vasculopathy; six from post-transplant lipoproliferative disorder; four from acute late rejection; two from sepsis; and one from multiorgan failure. Causes of death for the other eight patients are unknown, Copeland said.
Actuarial survival rates for the entire cohort of 337 pediatric heart transplantation recipients were 57% at 15 years, 47% at 20 years and 43.6% at 25 years. For the 183 recipients who survived at least 15 years, actuarial survival rates were 82% at 20 years and 78% at 25 years, she said.
Application of the data today
The researchers said, however, that today’s pediatric heart transplant recipients are more seriously ill than those from the study period (1985-1998). It is uncertain whether the same survival statistics can be expected in the future.
“During [the study period], there were shorter wait-list times and fewer advanced therapy options,” Copeland said during the press conference. “In the recent era, things are different. [Today’s patients] have longer wait-list times, they’ve had more palliative procedures prior to transplant, they’ve become more sensitized, and there’s been an increased use of mechanical circulatory support.”
Better than expected
In an invited commentary, Thomas L. Spray, MD, of The Children’s Hospital of Philadelphia, said the survival rates are much better than what doctors were expecting when it became possible to perform pediatric heart transplants.
Thomas L. Spray
“In the early days of transplantation, many of us felt that this was extremely palliative therapy, that many of these children would not survive into adulthood and that this would be at least a temporary solution to very complex congenital heart disease that had no other good surgical or medical options,” he said. “What we’re seeing with this kind of information is that in fact it’s good palliation, and that this palliation extends well into adulthood, certainly into the 20s.” – by Erik Swain
For more information:
Copeland H. General Session II: Hot Topics in Cardiothoracic Surgery – Congenital. Presented at: STS 50th Annual Meeting; Jan. 25-29, 2014; Orlando, Fla.
Disclosure: Copeland and Spray report no relevant financial disclosures.