title: Era effect on survival following paediatric heart transplantation.
abstract: OBJECTIVE
  Paediatric heart transplantation is performed to salvage children with end-stage heart failure from various underlying pathologies. Despite several developments in all management aspects of transplantation candidates, the effect of those advances on outcomes has not been consistent. We report our institutional experience with focus on examining era effect on early and late survival.
  
  
  METHODS
  Between 1988 and 2015, 320 children underwent heart transplantation. Competing risk analysis modelled events after transplantation (retransplantation, death without retransplantation). Multivariable parametric risk hazard analysis examined the risk factors affecting survival.
  
  
  RESULTS
  Patients were divided to three groups based on underlying pathology: congenital group (n = 132, 41%), acquired group (n = 153, 48%) and retransplant group (n = 35, 11%). Competing risk analysis showed that at 10 years following transplantation, 11% of patients had undergone retransplantation, 39% had died without retransplantation and 44% were alive without retransplantation. Ten-year survival was 61, 51 and 45% for acquired, congenital and retransplant groups, respectively. Overall, survival following heart transplantation for the late era (2005-15) was 63% compared with 49% for the early era (1988-2004) at 10 years (P = 0.022). Compared with early era, 1-year survival in the late era was 84 vs 79% {odds ratio (OR): 0.72 [95% confidence interval (CI) 0.3-1.8], P = 0.470} for congenital, 98 vs 86% [OR: 0.14 (95% CI 0.03-0.68), P = 0.006] for acquired and 73 vs 88% [OR: 2.6 (95% CI 0.4-1.9), P = 0.282] for retransplant. The effect of late era on survival was not significant for congenital [hazard ratio (HR) 0.6 (95% CI 0.2-1.4), P = 0.206] or retransplant patients [HR: 1.7 (95% CI 0.5-5.5), P = 0.400], but showed improvement trend for acquired patients [HR: 0.53 (95% CI 0.3-1.0), P = 0.052].
  
  
  CONCLUSIONS
  The era effect on early survival following heart transplantation is related to underlying pathology; there is a significant improvement in early survival in children with acquired pathology, whereas there is no significant change in early survival in children with congenital pathology or failed prior transplantation. This suggests a potential area for improvement that might include pretransplant stabilization and management of immunosuppression. On the other hand, era effect on late survival is not significant. This demonstrates that advances in the care of paediatric heart transplantation patients have not affected ongoing problems that diminish late survival.
authors.affiliation: Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA balsoufi@hotmail.com.
authors.forename: Bahaaldin
authors.initials: B
authors.lastname: Alsoufi
authors.affiliation: Department of Pediatrics, Division of Cardiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA.
authors.forename: Shriprasad
authors.initials: S
authors.lastname: Deshpande
authors.affiliation: Department of Pediatrics, Division of Cardiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA.
authors.forename: Courtney
authors.initials: C
authors.lastname: McCracken
authors.affiliation: Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA.
authors.forename: Brian
authors.initials: B
authors.lastname: Kogon
authors.affiliation: Department of Pediatrics, Division of Cardiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA.
authors.forename: Robert
authors.initials: R
authors.lastname: Vincent
authors.affiliation: Department of Pediatrics, Division of Cardiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA.
authors.forename: William T
authors.initials: WT
authors.lastname: Mahle
authors.affiliation: Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA.
authors.forename: Kirk
authors.initials: K
authors.lastname: Kanter
mesh_terms: D002648:Child; D002675:Child, Preschool; D005260:Female; D006330:Heart Defects, Congenital / Q000401:mortality / Q000601:surgery; D006331:Heart Diseases / Q000401:mortality / Q000601:surgery; D016027:Heart Transplantation / Q000401:mortality*; D006801:Humans; D008297:Male; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D016019:Survival Analysis; D013997:Time Factors
keywords: Cardiomyopathy; Congenital heart disease; Heart transplantation; Mechanical circulatory support