Pediatric heart-lung transplantation: A contemporary analysis of outcomes.

Abstract

Pediatric heart-lung transplantation (HLT) is rare, and no report has analyzed patient outcomes since time of listing. We analyzed pediatric HLTs to understand risk factors for waitlist and post-HLT mortality. All pediatric (<18year old) HLT candidates were identified within the UNOS database (n=573) and grouped by age, era, and by diagnosis. Logistical regression and Cox proportional hazard modeling identified risk factors for 6-month WL and overall post-transplant mortality. 209/573 (37%) HLT candidates were transplanted, 7% recovered, 42% died waiting, and 15% were removed for another/unknown reason. Diagnoses were primary pulmonary hypertension(n=130), congenital heart disease(CHD) without Eisenmenger's syndrome (ES) (n=65), CHD with ES (n=73), and other (n=305). Patients with a diagnosis other than CHD with ES (OR: 7.55, P=.001), on IV inotropic support (OR: 2.79, P<.001), and infants (OR: 2.20, P=.004) were associated with waitlist mortality. There has been a 56% reduction in HLTs across eras (Era 1:10.8/yr vs Era 2:4.7/yr). Risk factors for post-transplant mortality were ECMO (HR: 4.1, P=.016), and being infant (HR: 2.2, P=.04) or 1-11years old (HR: 1.78, P=.015). ECMO patients have an 87% 2-year mortality rate with a median post-transplant survival of 64days. Overall, post-transplant survival was unchanged (log-rank P=.067) between eras. Excluding ECMO patients, in the recent era 29 non-infant patients with primary pulmonary hypertension had 93% 1-year survival and 67% 5-year survival. Nearly 600 pediatric patients have been listed for HLT in UNOS, although numbers are decreasing in the current era. HLT for a patient on ECMO appears to be an ineffective strategy; however, in well-selected cohorts, HLT can provide considerable post-transplant survival.