Over Sized Adult Hearts Can Be Used for Paediatric Transplant Recepients with Good Medium Term Outcomes

Abstract

Purpose Finding ideal donor hearts perfectly matched for age and weight is a challenge, especially for very sick children. This is a retrospective study evaluating the use of oversized adult hearts for children. Methods Over a 6 year period, 73 children, aged 1 to 17,(median 12) had a heart transplant in our unit. 10 of these patients had a preoperative cardiac arrest, resuscitated with ECMO (ECPR) . ECMO was converted to centrimag in 4 patients. 58 patients received hearts from donors less than 40 years of age,median age 22 (Group A) 15 patients received hearts from donors over 40 years of age, median age 52, recepient age range 8 to 18. (Group B) 35 patients had donor to recipient weight ratio (D:R) less than 2, and 38 had D:R more than 2(maximum D:R of 5) Results There were 7 early deaths and 5 late deaths in the first year after surgery in the entire series.(84 % one year survival) There were no further late deaths in a followup of upto 5 years. The one year survival in both group A and B was similar. 83 vs 80 %.. However 5 patients in group B had evidence of donor coronary artery disease in coronary angiogram done within a year of transplant and 3 have undergone stenting . out of the 39 patients with D:R more than 2,there were 6 early and 2 late deaths(one year survival of 79.5 %). Of the 43 patients with D:R less than 2,there were 2 early and 4 late deaths.(one year survival of 86 %). There were 3 patients who had a delayed chest closure for upto 48 hours after surgery due to size mismatch with no adverse outcomes. 5 patients had a “big heart syndrome with cerebral hyper perfusion and convulsions with hypertension early on in the series. there were 2 early and 2 deaths in this cohort. All these patients were very sick,intermacs 2 and received hearts with excellent ventricular function,with a D: R ratio ranging from 1.47 TO 3.8, median 2.7. with aggressive control of blood pressure and excessive cardiac output, this syndrome is no longer seen. Over sized hearts even with significant ventricular dysfunction seem to function well in smaller recepients. 7 out of 10 patients of ECPR are alive at one year follow up after transplant Conclusion Hearts from oversized adults including those with significant dysfunction can be used safely in children with very good medium term results of 84 % actuarial survival at 5 years. Children receiving hearts from donors over the age of 40,need careful followup for evidence of coronary artery disease.