Brighter Future for Children with Congenital Heart Disease Requiring Heart Transplantation? A UNOS Registry Analysis over the Last Three Decades

Abstract

Patients with congenital heart disease (CHD) account for ∼40% of pediatric heart transplants (HT) performed in the United States. Our aim was to evaluate the overall trends for waitlist and post-transplant survival for children with CHD in the last three decades and identify risk factors for waitlist and post-transplant mortality in the current era. Children (age <18, n= 5741) listed for HT in the UNOS database from 1990-2017 were included. Patients were divided by time at initial listing into Era 1 (1/1/90-3/12/99), Era 2 (3/13/99-12/31/08) and Era 3 (1/1/09-12/31/17). Demographic and clinical characteristics at listing, including ventricular assist device (VAD) use, were compared across the 3 eras. Kaplan-Meier curves were generated to compare survival in the waitlist and post-transplant periods. We identified risk factors for increased waitlist and post-transplant mortality by bootstrap selection method. Compared to Era 1, CHD candidates in Eras 2 and 3 were older (mean age 3.5±5.4 vs 4.0±5.5 vs 4.2±5.5 years), more often of non-White race (26.7 vs 39.7 vs 41.6%), more likely on intravenous inotropes (31.1 vs 45.7 vs 46.6%) and on VAD support (1.1 vs 2.3 vs 3.2%). Compared to Era 2, those in Era 3 were less likely to have renal dysfunction (71.5 vs 54.0%) and pulmonary hypertension (27.8 vs 17.1%) or be on ECMO (14.8 vs 8.1%) or ventilator (29.8 vs 23.0%) pre-transplant. Compared to earlier Eras, children with CHD listed for HT in Era 3 had significantly improved 1-year waitlist (59.6 vs 58.4 vs 67.5%) and post-transplant survival (75.3 vs 80.6 vs 88.0%) (Figure) [p<0.05 for all]. Multivariable risk factors for waitlist and post-transplant mortality in Era 3 are shown in Table. Children with CHD listed for HT in the U.S. have had significant improvement in waitlist and post-transplant survival particularly in the last decade. Improved candidate selection and post-transplant care may have led to these advances.