Pediatric Heart Transplantation

Despite advances in medical management, patients submitted for heart transplantation procedures still are at risk to development of complications. This chapter will discuss some specific topics of pediatric heart transplantation, focusing on perioperative care: (i) recipient management, (ii) donor evaluation, (iii) immunosuppression, (iv) early postoperative management, (v) complications, and (vi) conclusions

Clinical research in pediatric organ transplantation

Solid organ transplantation has greatly improved survival in children with end-stage disease, becoming one of the main treatment options in this population. Nonetheless, there are significant challenges associated with validating and optimizing the effects of these interventions in clinical trials. Therefore, we reviewed the main issues related to conducting clinical transplantation research in children. We divided these challenges into three different categories: (i) challenges related to surgical techniques and anesthetic procedures, (ii) challenges related to post-transplant care and (iii) challenges specific to a particular population group and disease type. Some of the observed burdens for clinical research in this field are related to the limitations of conducting studies with a placebo or sham procedure, determining the standard of care for a control group, low prevalence of cases, ethical concerns related to use of a placebo control group and lack of generalizability from animal studies and clinical trials conducted in adult populations. To overcome some of these barriers, it is necessary to utilize alternative clinical trial designs, such as observational studies or non-inferiority trials, and to develop multicenter collaborations to increase the recruitment rate. In conclusion, the lack of robust data related to pediatric transplantation remains problematic, and further clinical trials are needed to develop more efficacious and safer treatments

Common challenge topics in pediatric transplantation

This special issue is dedicated to the common challenge topics in pediatric transplantation. It contains 11 chapters, ranging from clinical research in pediatric transplantation to translational research (from bench to bedside). It includes comprehensive reviews from renowned scientists, clinicians and surgeons from five countries from the International Pediatric Transplantation Association (IPTA), Harvard University, the University of Miami and the University of São Paulo Medical School. The clinical management of specific issues, such as sensitized patients and ABO blood type-incompatible transplantation, is addressed. In addition, the challenges facing this patient population and the future perspectives for clinical research are discussed

Delisting of infants and children from the heart transplantation waiting list after carvedilol treatment

AbstractObjectivesWe performed a prospective, randomized, double-blind, placebo-controlled study of carvedilol effects in children with severe, chronic heart failure (HF), despite the use of conventional therapy.BackgroundLittle is known about the effects of carvedilol in youngsters with chronic HF and severe left ventricular (LV) dysfunction.MethodsWe conducted a double-blind, placebo-controlled study of 22 consecutive children with severe LV dysfunction. The children had chronic HF and left ventricular ejection fraction (LVEF) <30%. Patients were randomly assigned to receive either placebo (8 patients) or the beta-blocker carvedilol (14 patients) at 0.01 mg/kg/day titrated up to 0.2 mg/kg/day, followed-up for six months.ResultsDuring the follow-up and the up-titration period in the carvedilol group, four patients died and one underwent heart transplantation. In patients receiving carvedilol evaluated after six months, a significant increase occurred in LVEF, from 17.8% (95% confidence interval [CI], 14.1 to 21.4%) to 34.6% (95% CI, 25.2 to 44.0%); p = 0.001. Modified New York Heart Association (NYHA) functional class improved in nine patients taken off the transplant waiting list. All nine patients were alive at follow-up. In the placebo group, during the six-month follow-up, two patients died, and two underwent heart transplantation. Four patients persisted with HF symptoms (NYHA functional class IV). No significant change occurred in LVEF or fractional shortening.ConclusionsCarvedilol added to standard therapy may reduce HF progression and improve cardiac function, allowing some youngsters to be removed from the heart transplantation waiting list

Terapia de ressincronizaçao cardíaca em criança com cardiopatia congênita complexa candidata a transplante cardíaco

Os autores relatam o caso de criança de 8 anos de idade com discordâncias atrioventricular e ventriculoarterial (transposiçao corrigida das grandes artérias) e insuficiência cardíaca congestiva crônica refratária, que apresentava retardo da ativaçao de ventrículo morfologicamente direito em posiçao sistêmica. A dissincronia cardíaca foi provocada pela estimulaçao ventricular exclusiva para o tratamento de bloqueio atrioventricular total consequente a fechamento de defeito do septo interventricular e correçao de regurgitaçao da valva atrioventricular. O implante do marcapasso atriobiventricular foi realizado por técnica híbrida, transtorácica e transvenosa, e a tática operatória foi definida com o auxílio de tomografia computadorizada do tórax. Após 4 anos de seguimento, a criança mantém melhora tanto clínica como funcional, a despeito da coexistência de alteraçoes em bioprótese valvar e ventrículo anatomicamente direito sob regime pressórico sistêmico

Terapia de ressincronizaçao cardíaca em criança com cardiopatia congênita complexa candidata a transplante cardíaco

Os autores relatam o caso de criança de 8 anos de idade com discordâncias atrioventricular e ventriculoarterial (transposiçao corrigida das grandes artérias) e insuficiência cardíaca congestiva crônica refratária, que apresentava retardo da ativaçao de ventrículo morfologicamente direito em posiçao sistêmica. A dissincronia cardíaca foi provocada pela estimulaçao ventricular exclusiva para o tratamento de bloqueio atrioventricular total consequente a fechamento de defeito do septo interventricular e correçao de regurgitaçao da valva atrioventricular. O implante do marcapasso atriobiventricular foi realizado por técnica híbrida, transtorácica e transvenosa, e a tática operatória foi definida com o auxílio de tomografia computadorizada do tórax. Após 4 anos de seguimento, a criança mantém melhora tanto clínica como funcional, a despeito da coexistência de alteraçoes em bioprótese valvar e ventrículo anatomicamente direito sob regime pressórico sistêmico

Clinical recommendations for postoperative care after heart transplantation in children: 21 years of a single-center experience

Heart transplantation is an option for children with complex congenital heart disease and cardiomyopathies. A patient's quality of life and long-term survival depend on successful management of the surgical complications and adverse side effects of immunosuppression. The purpose of this review was to summarize the practical management of postoperative care in this patient population and to make recommendations for the future

Pediatric heart transplantation in refractory cardiogenic shock: a critical analysis of feasibility, applicability and results

FUNDAMENTO: Considerando crianças com miocardiopatia dilatada, na lista de espera de transplante de coração, podemos avaliar a gravidade do quadro hemodinâmico desses pacientes. Alguns apresentam choque cardiogênico e um elevado índice de mortalidade. Mesmo com suporte inotrópico e respiratório, o transplante de coração é considerado uma condição de extrema gravidade. OBJETIVO: Apresentar nossa experiência com crianças na circunstância de transplante cardíaco em vigência de choque cardiogênico refratário, procurando analisar a viabilidade, a aplicabilidade e os resultados desses transplantes. MÉTODOS: De março de 2001 a fevereiro de 2004, 22 crianças com miocardiopatia dilatada, previamente registradas na lista de transplante, apresentaram choque cardiogênico, necessitando transferência para unidade de terapia intensiva (UTI) pediátrica, intubação e suporte inotrópico. As idades variaram de 11 meses a 11 anos (média = 4,3 idade), com 55% do sexo masculino; 14 poderiam ser listados como prioridade clínica e os outros 8 foram excluídos da lista de espera em razão de condição clínica desfavorável. RESULTADOS: Oito transplantes de coração foram executados, 6 crianças faleceram na fila de espera (42,9%). Duas crianças faleceram (25%) após o transplante; as outras 6 receberam alta hospitalar com boas condições clínicas. As duas principais complicação são rejeição, em 4 casos, e infecção, em 5 casos. Dois apresentaram complicações neurológicas, com recuperação total em um dos casos. CONCLUSÃO: Crianças com miocardiopatia e choque cardiogênico necessitam de transplante imediato; somente 57,1% podiam ser transplantadas, com mortalidade de 25%. Daquelas que sobreviveram ao transplante, a evolução clínica foi boa, similar às crianças transplantas em cirurgias eletivas.BACKGROUND: In children with dilated cardiomyopathy who are on the waiting list for heart transplantation, we evaluate the seriousness of their hemodynamic conditions. Some develop cardiogenic shock, and the mortality rate is high. Even with inotropic and respiratory support, heart transplantation is considered an extremely grave circumstance. OBJECTIVE: The objective of this study is to report on our experience with children in this condition, in an attempt to analyze the viability, applicability and results of heart transplantation in these children. METHODS: From March 2001 to February 2004, 22 children with dilated cardiomyopathy who were on the waiting list for heart transplantation developed cardiogenic shock, requiring transfer to pediatric intensive care unit (ICU), intubation and inotropic support. Their ages ranged from 11 months to 11 years (mean age: 4.3 years), 55% were males, 14 could be listed as clinical priority, and the remaining 8 were removed from the waiting list due to their unfavorable clinical conditions. RESULTS: Eight heart transplantations were performed, and 6 children died while on the waiting list (42.9%). Two children died (25%) after transplantation and the remaining 6 were discharged from hospital in good clinical condition. The two main complications were organ rejection in 4 cases and infection in 5 cases. Two patients developed neurological complications, and one of them fully recovered. CONCLUSION: Children with cardiomyopathy and cardiogenic shock require immediate heart transplantation; only 57.1% could be transplanted, with an early 25% mortality rate. Those who survived transplantation showed good clinical progress, similar to that of children transplanted on an elective basis