Pediatric heart-lung transplantation: A contemporary analysis of outcomes

Pediatr Transplant. 2020 May;24(3):e13682. doi: 10.1111/petr.13682. Epub 2020 Feb 17.

Abstract

Background: Pediatric heart-lung transplantation (HLT) is rare, and no report has analyzed patient outcomes since time of listing. We analyzed pediatric HLTs to understand risk factors for waitlist and post-HLT mortality.

Methods: All pediatric (<18 year old) HLT candidates were identified within the UNOS database (n = 573) and grouped by age, era, and by diagnosis. Logistical regression and Cox proportional hazard modeling identified risk factors for 6-month WL and overall post-transplant mortality.

Results: 209/573 (37%) HLT candidates were transplanted, 7% recovered, 42% died waiting, and 15% were removed for another/unknown reason. Diagnoses were primary pulmonary hypertension(n = 130), congenital heart disease(CHD) without Eisenmenger's syndrome (ES) (n = 65), CHD with ES (n = 73), and other (n = 305). Patients with a diagnosis other than CHD with ES (OR: 7.55, P = .001), on IV inotropic support (OR: 2.79, P < .001), and infants (OR: 2.20, P = .004) were associated with waitlist mortality. There has been a 56% reduction in HLTs across eras (Era 1:10.8/yr vs Era 2:4.7/yr). Risk factors for post-transplant mortality were ECMO (HR: 4.1, P = .016), and being infant (HR: 2.2, P = .04) or 1-11 years old (HR: 1.78, P = .015). ECMO patients have an 87% 2-year mortality rate with a median post-transplant survival of 64 days. Overall, post-transplant survival was unchanged (log-rank P = .067) between eras. Excluding ECMO patients, in the recent era 29 non-infant patients with primary pulmonary hypertension had 93% 1-year survival and 67% 5-year survival.

Conclusions: Nearly 600 pediatric patients have been listed for HLT in UNOS, although numbers are decreasing in the current era. HLT for a patient on ECMO appears to be an ineffective strategy; however, in well-selected cohorts, HLT can provide considerable post-transplant survival.

Keywords: Eisenmenger's syndrome; congenital heart disease; extracorporeal membrane oxygenation; heart-lung transplant; primary pulmonary hypertension; waitlist.

MeSH terms

  • Adolescent
  • Child
  • Child, Preschool
  • Databases, Factual
  • Female
  • Heart-Lung Transplantation / mortality*
  • Humans
  • Infant
  • Infant, Newborn
  • Kaplan-Meier Estimate
  • Logistic Models
  • Male
  • Outcome Assessment, Health Care
  • Proportional Hazards Models
  • Retrospective Studies
  • Risk Factors
  • Survival Rate
  • United States / epidemiology
  • Waiting Lists / mortality*