Survival after listing for cardiac transplantation in children

Despite improvement in surgical and medical management of children with con genital and acquired heart disease, cardiac transplantation remains an impo rtant therapeutic option for infants and children with end-stage heart dise ase. Ultimate survival in patients who are listed for transplantation is a function of both mortality while awaiting transplantation and survival afte r transplantation. Survival of heart transplantation is affected by the sev erity of illness before transplantation, the unique pathophysiology of cert ain defects, and the availability of donor hearts. Outcome following listin g for transplantation is best studied with the use of recent modifications in statistical methods of competing outcomes analysis. By this analysis a p redicted mortality while waiting among all pediatric patients is 20% at 1 y ear, with 67% undergoing transplantation, 10% still on the list awaiting tr ansplant, and 3% removed from the list. Among infants, most of them with hy poplastic left heart syndrome, 60% will have transplantation by 6 months af ter listing, with 27% of patients dying while waiting. In infants the major risk factors for death while waiting are the need for inotropic support at listing, smaller size, and recipient blood type. In older children risk fa ctors for death while waiting are Status 1 at listing and a need for mechan ical ventilation. Intermediate-term survival after transplant is excellent in all age groups with 86% alive at 6 months, 84% at 1 year, and 73% at 5 y ears. Survival after transplant in infants is comparable to survival in old er children, although the early mortality after transplantation is greater. Infants who have recently undergone sternotomy or received organs from don ors who did not die of closed head trauma are more likely to die early afte r transplant. Among older children risk factors for death after transplanta tion include the need for a mechanical support device or a younger age in p atients greater than 1 year of age. Death following transplantation is prim arily related to early graft failure in infants, whereas rejection, infecti on, and sudden death account for the majority of deaths in older children. Although improved immunosuppressive agents promise to lead to even better s urvival rates after transplantation, greater access to donors is essential if overall survival is to be improved. (C) 2000 Elsevier Science Ireland Lt d. All rights reserved.