Early predictors of survival to and after heart transplantation in children with dilated cardiomyopathy

Abstract

Background: The importance of clinical presentation and pretransplantation course on outcome in children with dilated cardiomyopathy listed for heart transplantation is not well defined.

Methods and results: The impact of age, duration of illness, sex, race, ventricular geometry, and diagnosis of myocarditis on outcome in 261 children with dilated cardiomyopathy enrolled in the Pediatric Cardiomyopathy Registry and Pediatric Heart Transplant Study was studied. End points included listing as United Network for Organ Sharing status 1, death while waiting, and death after transplantation. The median age at the time of diagnosis was 3.4 years, and the mean time from diagnosis to listing was 0.62±1.3 years. Risk factors associated with death while waiting were ventilator use and older age at listing in patients not mechanically ventilated (P=0.0006 and P=0.03, respectively). Shorter duration of illness (P=0.04) was associated with listing as United Network for Organ Sharing status 1. Death after transplantation was associated with myocarditis at presentation (P=0.009), nonwhite race (P<0.0001), and a lower left ventricular end-diastolic dimension z score at presentation (P=0.04). In the myocarditis group, 17% (4 of 23) died of acute rejection after transplantation.

Conclusions: Mechanical ventilator use and older age at listing predicted death while waiting, whereas nonwhite race, smaller left ventricular dimension, and myocarditis were associated with death after transplantation. Although 97% of children with clinically or biopsy-diagnosed myocarditis at presentation survived to transplantation, they had significantly higher posttransplantation mortality compared with children without myocarditis, raising the possibility that preexisting viral infection or inflammation adversely affects graft survival.

Figure 1

Kaplan-Meier survival curve for the first two years after listing (censored at transplantation) for children with DCM (n=261, 26 deaths by two years after listing). The error bars represent 70% confidence limits.

Figure 2

Kaplan-Meier survival curves after listing (censored at transplantation) for patients who were (Yes vent) and were not (No vent) mechanically ventilated at listing. The error bars represent 70% confidence limits.

Figure 3

3(a). Kaplan-Meier post transplantation survival curve for children with DCM (n=209). 3(b). Kaplan Meier post-transplantation curve for children < 1 year, 1-10 years, and >10 years of age at transplantation. 3(c). Kaplan-Meier post–transplantation survival curves for children with non-white versus white race. The error bars represent 70% confidence limits.

Figure 3

3(a). Kaplan-Meier post transplantation survival curve for children with DCM (n=209). 3(b). Kaplan Meier post-transplantation curve for children < 1 year, 1-10 years, and >10 years of age at transplantation. 3(c). Kaplan-Meier post–transplantation survival curves for children with non-white versus white race. The error bars represent 70% confidence limits.

Figure 3

3(a). Kaplan-Meier post transplantation survival curve for children with DCM (n=209). 3(b). Kaplan Meier post-transplantation curve for children < 1 year, 1-10 years, and >10 years of age at transplantation. 3(c). Kaplan-Meier post–transplantation survival curves for children with non-white versus white race. The error bars represent 70% confidence limits.

Figure 4

4(a) Kaplan-Meier post–transplantation survival curve for children with the diagnosis of myocarditis versus no myocarditis (at presentation). 4(b) Kaplan-Meier curves comparing freedom from rejection death post-transplantation for children with the diagnosis of myocarditis versus no myocarditis. The error bars represent 70% confidence limits.

Figure 4

4(a) Kaplan-Meier post–transplantation survival curve for children with the diagnosis of myocarditis versus no myocarditis (at presentation). 4(b) Kaplan-Meier curves comparing freedom from rejection death post-transplantation for children with the diagnosis of myocarditis versus no myocarditis. The error bars represent 70% confidence limits.