Outcomes of Third Heart Transplants in Pediatric and Young Adult Patients

Purpose Repeat heart transplantation (re-HTx) is standard practice in many pediatric centers, with acceptable outcomes in appropriate patients (pts). There are little data available on outcomes of 3 r4 HTx following failure of a 2 144 graft. We sought to compare outcomes of 3 r4 HTx in pediatric and young adult pts to outcomes of comparable pts with 2 144 HTx. Methods and Materials All recipients of 3 r4 HTx in whom primary HTx was prior to age 21 were identified in the United Network of Organ Sharing (UNOS) database (1985-2011) and matched 3:1 with a control group of 2 144 HTx pts by age, era, and re-HTx indication. The primary outcome measure was 1 and 5 year (yr) survival; secondary outcomes included inter-group differences in rejection and cardiac allograft vasculopathy (CAV). Results At time of HTx, cases (n=27) and controls (n=79) were alike in sensitization (PRA > 10 in 29.6% vs 29.1%, p= 0.94), serum creatinine (median 1.2 vs 1.1, p=0.30), bilirubin (median 0.8 vs 0.6, p=0.79), hospitalization (33.3% vs 53.2%, p=0.08), inotropic support (25.9% vs 41.8%, p=0.14) and mechanical ventilation (7.4% vs 7.6%, p=1.0). Inter-HTx interval was shorter for cases than controls (median 5.0 yr vs 9.8 yr, p=0.001). There was no difference in survival between groups at 1 and 5 yrs (76% vs 80% at 1 yr and 62% vs 58% at 5 yrs, p=0.75). The prevalence of rejection within the first yr (33.3% vs 44.3%, p=0.32) and post-HTx CAV (14.8% vs 30.4%, p=0.11) were comparable between groups. Risk factors for non-survival in 3 r4 HTx pts were: mechanical ventilation at HTx (Hazard ratio (HR) 8.4, 95% confidence interval (CI) 1.5-46.5); ECMO support at HTx (HR 25.5, 95% CI 1.6-408); and elevated serum bilirubin at HTx (HR 2.3, 95% CI 1.2-4.2). Conclusions Third HTx remains rare in pediatric and young adult pts. Outcomes of 3 r4 HTx are similar to 2 144 HTx in matched pts, with no difference in short or long term survival and comparable rates of early rejection and CAV. Consideration of 3 r4 HTx appears reasonable in appropriately selected pts.