Indications and contraindications for heart transplantation in infancy.
Heart transplantation uniquely offers infants with irreversible myopathies and complex congenital heart disease (CCHD) the potential for survival. Heart transplantation in the first year of life has an actuarial 1-year survival rate of 85%. Controlling for the variables that lead to perioperative death can improve 1-year survival rates to 95%. Mortality is also accrued before transplantation, with 15% to 20% of infants dying before a donor organ is available. Because of this cumulative mortality, an algorithm was developed to maximize pre- and posttransplantation survival and thus increase the likelihood that the limited donor supply would have the greatest impact. The risk factors considered in the algorithm include: (1) hemodynamic stability, (2) central venous access/prostaglandin requirements, (3) need for ventilator support, (4) pulmonary blood flow dependent on a critically restricted atrial septal defect, (5) risk for pulmonary hypertension, (6) anomalous pulmonary venous return, and (7) history of sepsis. Overall, patient survival would be maximized by only using transplantation for patients with CCHD who have moderate or less risk of pre- or posttransplantation death (< 20%). Donor organ utilization could be maximized by reserving transplantation for patients without options (myopathies) and for patients with CCHD who have a low predicted risk of death (< 10%). Because the risks of death at transplantation or in the first year after transplantation are low and relatively fixed, changes in risks of palliative surgery or donor availability can be easily used to adjust the decision algorithm.
Boucek
M M
MM
Department of Pediatrics/Pediatric Cardiology, University of Colorado/The Children's Hospital, Denver.
Mathis
C M
CM
Razzouk
A
A
Gundry
S R
SR
Bailey
L L
LL
Fullerton
D A
DA
Campbell
D N
DN
D000075202:Contraindications; D016027:Heart Transplantation / Q000401:mortality; D006801:Humans; D007223:Infant; D012307:Risk Factors; D015996:Survival Rate