HETEROTOPIC CARDIAC TRANSPLANTATION IN INFANTS AND CHILDREN

Background: Children with advanced heart failure, particularly those w ith elevated pulmonary vascular resistance, pose a difficult managemen t problem because the normal donor right ventricle cannot cope with th e high pulmonary resistance and because of the relative shortage of do nor organs of an appropriate size for this age group. Methods: In an a ttempt to address these issues and evaluate the role of heterotopic tr ansplantation in this context, we operated on 12 children, six boys an d six girls, in the period between January 1, 1991, and March 31, 1996 . Their ages ranged from II months to 15.2 years (mean 81.6 +/- 62.8 m onths) and their mean weight was 23.3 kg (range 7.6 to 56.8 kg). Eight patients (66.6%) had significant elevation of pulmonary artery pressu re (pulmonary artery systolic pressure = 66 +/- 9.4 mm Hg, mean transp ulmonary gradient = 22.3 +/- 3.4 mm Hg). In all patients the donor pul monary artery was anastomosed to the recipient right atrium without th e use of any prosthetic material. Ischemic times varied between 135 an d 255 minutes (mean 182.1 +/- 30.7 minutes). The immunosuppression reg imen included cyclosporine and azathioprine. Steroids were not routine ly used. Results: One patient died in the hospital of acute rejection on postoperative day 16. Three patients had lobe collapse within 1 wee k and all were treated successfully. Two late deaths (18.2%) occurred as a result of cardiac rejection 3 months and 2 years after the operat ions. Nine survivors (75%) are alive, active, and growing normally at a mean follow-up of 2.2 years (range 11 months to 4.75 years). Repeate d cardiac catheterization performed in seven patients with preoperativ e pulmonary hypertension showed a slow progressive drop in mean pulmon ary artery pressure. No significant change was observed in the functio n of the recipient hearts. Conclusion: We conclude that heterotopic he art transplantation is feasible for a selected group of children with good medium-term results, notably regression of pulmonary artery press ure, normal growth, and lack of long-term chest complications.