Pediatric retransplantation

Previous studies have attempted to outline the efficacy of heart retransplantation in adults. A limited number of these retransplantation procedures have been performed in children; however, no study to date has evaluated the risk of heart retransplantation in this specific patient population. We conducted a retrospective review of 17 pediatric (non- neonatal) heart transplant recipients who subsequently underwent heart retransplantation. Thirteen male and four female patients underwent retransplantation at four different institutions between 1974 and 1992. Patient age at the time of primary transplantation ranged from 2 to 19 years (mean, 12.5 years) and from 3 to 30 years (mean, 16 years) at retransplantation. The time interval between transplantation procedures ranged from 2 days to 15.6 years and was not predictive of patient outcome. Follow-up after retransplantation ranged from 1 day to 11 years (mean, 2.8 years). All patients were New York Heart Association class 3 or class 4 at the time of retransplantation. After retransplantation all survivors were New York Heart Association class 1. No patient had mechanical device implantation or extracorporeal membrane oxygenation bridge-to-transplantation at primary transplantation or retransplantation. The indication for retransplantation was transplant coronary artery disease (TxCAD) in seven patients (41.2%), acute rejection in four (23.5%), chronic rejection in one (5.8%), chronic rejection associated with TxCAD in four (23.5%), and intraoperative donor organ failure in one (5.8%). No significant difference occurred in linearized rates of rejection or infection or in actuarial freedom from rejection or infection when secondary grafts were compared with primary grafts in patients undergoing retransplantation. However, there was a trend toward earlier and more frequent rejections in the primary grafts as opposed to the secondary grafts of recipients undergoing retransplantation. Three of the 16 survivors undergoing retransplantation developed TxCAD in the secondary graft between 3 and 16 months after surgery, which resulted in one death. The indication for retransplantation in all three of these patients was TxCAD. Other causes of death included acute rejection (two); posttransplantation lymphoproliferative disorders (one); infection (two); suicide (one); and unknown (one). Actuarial 1- and 3-year survival rates were 71% and 47%, respectively. Patients surviving longer than 6 months after retransplantation appear to have a better actuarial survival rate than the overall retransplant population.