DONOR-RECIPIENT SIZE MATCHING IN PEDIATRIC HEART-TRANSPLANTATION - A WORD OF CAUTION ABOUT SMALL GRAFTS

B ackground: The increased shortage of donor organs led centers to ext end the conventional donor criteria, particularly regarding donor-reci pient size mismatching. Little information is available in the pediatr ic age group. Methods: Between December 1987 and May 1994, 73 pediatri c orthotopic heart transplantations were performed. Indications for he art transplantation included congenital heart defect (29 patients), ca rdiomyopathy (40 patients), valvular disease (1 patient), and retransp lantation (3 patients). Patients ranged in age from 9 days to 18 years (mean: 5.7 +/- 5 years). The following factors were evaluated: cardio myopathy, congenital heart disease, age, pretransplantation pulmonary hypertension, previous sternotomy, status at transplantation, donor to recipient weight ratio, graft ischemic time, degree of donor inotropi c support, ABO compatibility, gender mismatch. Results: The overall mo rtality rate before discharge (7 days to 4.5 months) was 27.4%. Donor heart failure occurred in 31.5%. Donor heart failure and early mortali ty were strongly correlated (p = 0.0002). Risk factors for donor heart failure were pretransplantation pulmonary hypertension (p = 0.024), d onor/recipient ratio (p = 0.033), and major donor inotropic support (p = 0.034). Donor heart failure rate was 50% in donor/recipient ratio l ess than 1, 33% in donor/recipient ratio between 1 and 1.6, and 7% in donor/recipient ratio more than 1.6. Donor/recipient ratio less than 1 was the only significant risk of postoperative death by univariate (p = 0.0045) and multivariate (p < 0.01) analysis. Conclusions: Donor he art failure remains the main cause of early mortality in pediatric hea rt transplantation. The use of oversized donor may be beneficial, part icularly in patients with pretransplantation pulmonary hypertension. T he use of undersized donor grafts should be strongly discouraged.