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AIM To describe the clinical and hemodynamic characteristics of Fontan failure in children listed for heart transplant. METHODS In a nested study of the Pediatric Heart Transplant Society, 16 centers contributed information on Fontan patients listed for heart transplant between 2005and 2013. Patients were classified into four mutually exclusive phenotypes: Fontan with abnormal lymphatics (FAL), Fontan with reduced systolic function (FRF), Fontan with preserved systolic function (FPF), and Fontan with "normal" hearts (FNH). Primary outcome was waitlist and post-transplant mortality. RESULTS 177 children listed for transplant were followed over a median 13 (IQR 4-31) months, 84 (47%) were FAL, 57 (32%) FRF, 22 (12%) FNH, and 14 (8%) FPF. Hemodynamic characteristics differed between the 4 groups: Fontan pressure (FP) was most elevated with FPF (median 22, IQR 18-23, mmHg) and lowest with FAL (16, 14-20, mmHg); cardiac index (CI) was lowest with FRF (2.8, 2.3-3.4, L/min/m2). In the entire cohort, 66% had FP >15 mmHg, 21% had FP >20 mmHg, and 10% had CI

Coronary allograft vasculopathy (CAV) is a leading cause of mortality after heart transplantation (HT) in children. Variation in CAV screening practices may impact detection rates and patient outcomes.Among 50 Pediatric Heart Transplant Society (PHTS) sites from 2001 to 2016, coronary evaluations were classified as angiography or non-invasive testing, and angiograms were designated as routine or symptom based. CAV detection rates stratified by routine vs symptom-based angiograms were calculated. Freedom from CAV and mortality after CAV diagnosis, stratified by study indication, were calculated.A total of 3,442 children had 13,768 coronary evaluations; of these, 97% (n = 13,012) were for routine surveillance, and only 3% (n = 333) were for cause. Over the study period, CAV was detected in 472 patients (14%). Whereas 58% (n = 29) of PHTS sites evaluate by angiography alone, 42% reported supplementing with a non-invasive test, although only 423 non-invasive studies were reported. Angiographic detection of CAV was higher for symptom-based testing than for routine testing (29% vs 4%, p0.0001), although routine testing identified a majority of cases (88%; n = 414). The 10-year freedom from CAV was 77% overall. Once CAV is detected, 5-year graft survival was 58%, with lower survival for patients diagnosed after symptoms angiogram than after routine angiogram (30% vs 62%; p0.0001).Development of a robust model for CAV risk should allow low-risk patients to undergo less frequent invasive angiography without adverse impact on CAV detection rates or outcomes.

BACKGROUND: Heart failure results in significant morbidity and mortality for young children with hypoplastic left heart syndrome (HLHS) following the Norwood procedure. METHODS: We studied subjects enrolled in the prospective Single Ventricle Reconstruction (SVR) trial who survived to hospital discharge after the Norwood operation and were followed up to age 6 years. The primary outcome was heart failure, defined as heart transplant listing after Norwood hospitalization, death attributable to heart failure or symptomatic heart failure (NYHA class IV). Multivariate modeling was undertaken using Cox regression methodology to determine variables associated with heart failure. RESULTS: Of the 461 subjects discharged to home following Norwood procedure, 66 (14.3%) met criteria for heart failure. Among these, 15 died from heart failure, 39 were listed for transplant (22 had a transplant, 12 died after listing and 5 were alive and not yet transplanted), and 12 had NYHA Class IV heart failure but were never listed. The median age at heart failure identification was 1.28 yrs (interquartile range 0.30 - 4.69 years). Factors associated with heart failure included post-Norwood lower fractional area change, need for ECMO, non-Hispanic ethnicity, Norwood perfusion type and total support time (p

Post-Fontan protein-losing enteropathy (PLE) is associated with significant morbidity and mortality. Although heart transplantation (HTx) can be curative, PLE may increase the risk of morbidity before and after HTx. This study analyzed the influence of PLE influence on waiting list and post-HTx outcomes in a pediatric cohort.Fontan patients listed for HTx and enrolled in the Pediatric Heart Transplant Study from 1999 to 2012 were stratified by a diagnosis of PLE, and the association of PLE with waiting list and post-HTx mortality, rejection, and infection was analyzed.Compared with non-PLE Fontan patients (n = 260), PLE patients listed for HTx (n = 96) were older (11.9 years vs 7.6 years; p = 0.003), had a larger body surface area (1.1 m(2) vs 0.9 m(2); p = 0.0001), had lower serum bilirubin (0.5 vs 0.9 mg/dl; p = 0.01), lower B-type natriuretic peptide (59 vs 227 pg/ml; p = 0.006), and were less likely to be on a ventilator (3% vs 13%; p = 0.006). PLE patients had lower waiting list mortality than non-PLE Fontan patients (p0.0001). There were no intergroup differences for post-HTx survival or times to the first infection or rejection. PLE was not independently associated with increased post-HTx mortality at any time point.In this multicenter cohort, the diagnosis of PLE alone was not associated with increased waiting list mortality or post-HTx morbidity or mortality. Given the limitations of our data, this analysis suggests that PLE patients in the pediatric age group have outcomes similar to their non-PLE counterparts. Additional multicenter studies of PLE patients with targeted collection of PLE-specific information will be necessary to fully delineate the risks conferred by PLE for HTx.

Background Repeat heart transplantation (re-HTx) is standard practice in many pediatric centers. There are limited data available on outcomes of third HTx after failure of a second graft. We sought to compare outcomes of third HTx in pediatric and young adult patients with outcomes of second HTx in comparable recipients. Methods All recipients of a third HTx in whom the primary HTx occurred before 21 years of age were identified in the United Network for Organ Sharing database (1985 to 2011) and matched 1:3 with a control group of second HTx patients by age, era and re-HTx indication. Outcomes including survival, rejection and cardiac allograft vasculopathy (CAV) were compared between groups. Results There was no difference between third HTx patients ( n = 27) and control second HTx patients ( n = 79) with respect to survival (76% vs 80% at 1 year, 62% vs 58% at 5 years and 53% vs 34% at 10 years, p = 0.75), early ( p = 0.32) or CAV (14.8% vs 30.4%, p = 0.11). Factors associated with non-survival in third HTx patients included mechanical ventilation at listing or HTx, extracorporeal membrane oxygenation support at listing or HTx, and elevated serum bilirubin at HTx. Conclusions Outcomes among recipients of a third HTx are similar to those with a second HTx in matched patients, with no difference in short- or long-term survival and comparable rates of early rejection and CAV. Although the occurrence of a third HTx remains relatively rare in the USA, consideration of a third HTx appears reasonable in appropriately selected patients.

Purpose: Pre-transplant (HTx) HLA-sensitization is associated with increased risk of post-HTx humoral rejection via donor-specific HLA antibodies (DSA). No universally accepted desensitizing protocol exists. This study details our 8-year experience using IVIg and Rituximab. Methods and Materials: The degree of HLA-sensitization was determined using ELISA or single-antigen bead Luminex assay with results expressed as median fluorescence intensity (MFI). Significantly sensitized patients were treated with one dose IVIg and serial Rituximab infusions. Serial HLA antibody measurement via calculated panel reactive antibody tests (CPRA) assessed treatment response. Paired t-tests compared the first and last CPRAs before HTx, death, or last follow-up. Results: Median follow-up was 5 2.8 months after the last Rituximab dose. 8/14 patients had a sustained (median 4 CPRAs/patient) decrease in circulating antibody assessed by ELISA or Luminex with reduction in class I and II CPRA from 50 25 to 17 36; p 0.009, and 61 26 to 17 38; p 0.045, respectively. Between responders and non-responders, there was no difference in median number of Rituximab doses (3 1.4 each) or patient age. However, 6/8 responders received 2 Rituximab doses before a significant PRA reduction was noted. Of the 14 patients, 1 died, 5 were delisted, and the remaining 8 (5 responders) underwent HTx using virtual crossmatching. One recipient made low-level DSA which cleared by 6 months post-HTx. Primary graft failure caused 2 post-HTx deaths; no patient had humoral rejection. Conclusions: Though not universal, a majority of allosensitized patients in this study experienced a significant reduction in HLA antibody after receipt of IVIg and Rituximab. For responders, this therapy increases the prospective donor pool through reduction in unacceptable antigens when using a virtual crossmatch process and may decrease waitlist mortality as well as post-HTx humoral rejection risk. IVIg and Rituximab appears to be a useful desensitization therapy and larger patient-base study is warranted.