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Comparative Study
. 2016 Jun;101(6):2321-7.
doi: 10.1016/j.athoracsur.2015.12.003. Epub 2016 Feb 22.

Modern Outcomes of Mechanical Circulatory Support as a Bridge to Pediatric Heart Transplantation

Affiliations
Comparative Study

Modern Outcomes of Mechanical Circulatory Support as a Bridge to Pediatric Heart Transplantation

Brody Wehman et al. Ann Thorac Surg. 2016 Jun.

Abstract

Background: Pediatric patients awaiting orthotopic heart transplantation frequently require bridge to transplantation (BTT) with mechanical circulatory support. Posttransplant survival outcomes and predictors of mortality have not been thoroughly described in the modern era using a large-scale analysis.

Methods: The United Network for Organ Sharing database was reviewed to identify pediatric heart transplant recipients from 2005 through 2012. Patients were stratified into three groups: extracorporeal membrane oxygenation (ECMO), ventricular assist device (VAD), and direct transplantation (DTXP). The primary outcome was posttransplant survival.

Results: Two thousand seven hundred seventy-seven pediatric patients underwent orthotopic heart transplantation. There were 617 patients who required BTT with mechanical circulatory support (22.2%), of whom there were 428 VAD BTT (69.4%) and 189 ECMO BTT (30.6%). An increase in VAD use was observed during the study period (p < 0.0001). Compared with DTXP, patients in the ECMO BTT group had a lower median age (<1 versus 5 years; p < 0.0001) and were significantly smaller (8 versus 14 kg; p < 0.001), whereas patients in the VAD BTT group were older (8 versus 5 years; p = 0.0002) and larger (24 versus 14 kg; p < 0.001). Actuarial survival was greater in the DTXP group compared with ECMO BTT, but similar to VAD BTT at 30 days and 1, 3, and 5 years. However, this survival difference was lost after censoring the first 4 months after transplant. In multivariable analysis, when restricted to the first 4 months of survival, independent predictors for mortality were ECMO BTT, age, diagnosis, and functional status, whereas VAD BTT was not.

Conclusions: Pediatric patients with DTXP or VAD BTT have equivalent posttransplant survival. However, those requiring ECMO BTT have inferior early posttransplant survival compared with those receiving DTXP.

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Figures

Fig 1
Fig 1
Percent of pediatric patients bridged to transplant using extracorporeal membrane oxygenation (ECMO; dark gray bars) or ventricular assist device (VAD; light gray bars) support per year (Cochran–Armitage p for trend <0.0001).
Fig 2
Fig 2
Kaplan-Meier survival curve for the first 4 months after transplant by bridge to transplant type (Wilcoxon p < 0.0001). (DTXP = direct transplantation [black line]; ECMO = extracorporeal membrane oxygenation [red line]; VAD = ventricular assist device [blue line].)
Fig 3
Fig 3
Kaplan-Meier survival curve by bridge to transplant type excluding the first 4 months after transplant (Wilcoxon p = 0.72). (DTXP = direct transplantation [black line]; ECMO = extracorporeal membrane oxygenation [red line]; VAD = ventricular assist device [blue line].)

Comment in

  • Invited Commentary.
    Wearden PD. Wearden PD. Ann Thorac Surg. 2016 Jun;101(6):2327-8. doi: 10.1016/j.athoracsur.2016.01.011. Ann Thorac Surg. 2016. PMID: 27211940 No abstract available.

References

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