title: Outcomes of third heart transplants in pediatric and young adult patients: analysis of the United Network for Organ Sharing database.
abstract: BACKGROUND
  Repeat heart transplantation (re-HTx) is standard practice in many pediatric centers. There are limited data available on outcomes of third HTx after failure of a second graft. We sought to compare outcomes of third HTx in pediatric and young adult patients with outcomes of second HTx in comparable recipients.
  
  
  METHODS
  All recipients of a third HTx in whom the primary HTx occurred before 21 years of age were identified in the United Network for Organ Sharing database (1985 to 2011) and matched 1:3 with a control group of second HTx patients by age, era and re-HTx indication. Outcomes including survival, rejection and cardiac allograft vasculopathy (CAV) were compared between groups.
  
  
  RESULTS
  There was no difference between third HTx patients (n = 27) and control second HTx patients (n = 79) with respect to survival (76% vs 80% at 1 year, 62% vs 58% at 5 years and 53% vs 34% at 10 years, p = 0.75), early (<1 year from HTx) rejection (33.3% vs 44.3%, p = 0.32) or CAV (14.8% vs 30.4%, p = 0.11). Factors associated with non-survival in third HTx patients included mechanical ventilation at listing or HTx, extracorporeal membrane oxygenation support at listing or HTx, and elevated serum bilirubin at HTx.
  
  
  CONCLUSIONS
  Outcomes among recipients of a third HTx are similar to those with a second HTx in matched patients, with no difference in short- or long-term survival and comparable rates of early rejection and CAV. Although the occurrence of a third HTx remains relatively rare in the USA, consideration of a third HTx appears reasonable in appropriately selected patients.
authors.affiliation: Division of Pediatric Cardiology, Department of Pediatrics and Communicable Disease, University of Michigan, Ann Arbor, Michigan. Electronic address: jmfriedl@med.umich.edu.
authors.forename: Joshua M
authors.initials: JM
authors.lastname: Friedland-Little
authors.affiliation: Division of Pediatric Cardiology, Department of Pediatrics and Communicable Disease, University of Michigan, Ann Arbor, Michigan.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Gajarski
authors.affiliation: Division of Pediatric Cardiology, Department of Pediatrics and Communicable Disease, University of Michigan, Ann Arbor, Michigan.
authors.forename: Sunkyung
authors.initials: S
authors.lastname: Yu
authors.affiliation: Division of Pediatric Cardiology, Department of Pediatrics and Communicable Disease, University of Michigan, Ann Arbor, Michigan.
authors.forename: Janet E
authors.initials: JE
authors.lastname: Donohue
authors.affiliation: Division of Pediatric Cardiology, Department of Pediatrics and Communicable Disease, University of Michigan, Ann Arbor, Michigan.
authors.forename: Mary C
authors.initials: MC
authors.lastname: Zamberlan
authors.affiliation: Division of Pediatric Cardiology, Department of Pediatrics and Communicable Disease, University of Michigan, Ann Arbor, Michigan.
authors.forename: Kurt R
authors.initials: KR
authors.lastname: Schumacher
mesh_terms: D000293:Adolescent; D000367:Age Factors; D016022:Case-Control Studies; D002648:Child; D002675:Child, Preschool; D016208:Databases, Factual; D005260:Female; D006084:Graft Rejection / Q000453:epidemiology / Q000601:surgery*; D006333:Heart Failure / Q000401:mortality / Q000601:surgery*; D016027:Heart Transplantation; D006801:Humans; D007223:Infant; D008297:Male; D012086:Reoperation; D012307:Risk Factors; D015996:Survival Rate; D009927:Tissue and Organ Procurement / Q000706:statistics & numerical data*; D016896:Treatment Outcome; D014850:Waiting Lists; D055815:Young Adult
keywords: allograft vasculopathy; ethics; heart transplant; pediatric cardiology; re-transplant; rejection; survival