EFFECT OF PREVIOUS CARDIAC SURGERY ON PEDIATRIC HEART TRANSPLANT RECIPIENTS

Abstract

390 To determine if prior cardiac surgery affects the risk in pediatric heart transplantation (tx), we analyzed 96 consecutive tx in 90 children since 1988. 38 (40%; mean age 5.8 ± 6.5 yrs) had no previous operations (Gp I); 58 (60% mean age 8.6 ± 5.4 yrs) had on average 3.4 previous cardiac operations (mean 1.9 sternotomies/pt). 68% Gp I pts were UNOS Status I at tx whereas 48% of Group II pts were Status I. There were 2 thirty-day deaths in each group giving a 30-day survival of 95% in the Gp I pts (one rejection death) and 97% in the redo Gp II pts (no rejection deaths). One Gp II pt underwent successful early retransplantation for graft failure. Cardiopulmonary bypass times (86 min vs 147 min; Gp I vs Gp II) were significantly longer in the reoperative Gp II pts (p< 0.0001); donor ischemic times were also longer (144 min vs 169 min; Gp I vs Gp II) but this did not reach statistical significance (p=0.056). Only 13% of the Gp I pts had bicaval anastomoses (vs atrial anastomoses) compared with 48% of the Gp II pts (p < 0.0001). 57% of the Gp II pts required pulmonary artery reconstruction, whereas none of the Gp I pts did. In the 30-day survivors, there were no statistically significant differences between the two groups looking at duration of post-op ventilation (2.1 d vs 3.9 d; Gp I vs Gp II), duration of inotropic support (2.6 d vs 3.1d; Gp I vs Gp II), ICU stay (5.1 d vs 8.5 d; Gp I vs Gp II), or hospital stay (12.0 d vs 16.2d; Gp I vs Gp II) although these values tended to be longer in the reoperative Gp II pts. Although freedom from rejection was significantly lower in the Group II pts at 30 days (48% vs 82%; p<0.01) and at 1 yr (27% vs 44%), actuarial survival was slightly higher at 1 yr (83% Gp II vs 74% Gp I) but not at 5 yrs (70% Gp II vs 68% Gp I) with a mean follow-up of 3.1 yrs in the Gp I pts and 3.2 yrs in the Gp II pts. 4 Gp I pts and 2 Gp II pts underwent successful late retransplantation. These results indicate that children with prior cardiac surgery can safely undergo successful cardiac transplantation compared with unoperated children. They are more likely to have early rejection presumably due to previous exposure to blood products with immune up-regulation (10% of Gp I pts had a PRA > 0 whereas 21% of Gp II pts had a PRA > 0). Early survival was no different in the operated patients despite more complicated and longer surgical procedures, as well as longer ICU and hospital stays. Intermediate survival and need for subsequent retransplantation is not different from those children who have not had prior cardiac surgery.