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Right arrow Congenital - acyanotic
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J Thorac Cardiovasc Surg 2010;139:146-153
© 2010 The American Association for Thoracic Surgery

Cardiothoracic Transplantation

Acute right ventricular failure after pediatric cardiac transplant: Predictors and long-term outcome in current era of transplantation medicine

Aparna Hoskote, MD, MRCPa,*, Catherine Carter, MSc, MPH, RNb, Phillip Rees, MB, FRCPb, Martin Elliott, MD, FRCSc, Michael Burch, MD, FRCP, FRCPCHb, Katherine Brown, MPH, MRCPa

a Cardiac Critical Care Unit, Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom
b Cardiothoracic Transplant Medicine, Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom
c Cardiothoracic Surgery, Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom

Received for publication December 23, 2008; revisions received July 3, 2009; accepted for publication August 10, 2009.

* Address for reprints: Aparna Hoskote, MD, MRCP, Consultant in Cardiac Critical Care, Cardiac Critical Care Unit, Great Ormond Street Hospital for Children NHS Trust, Great Ormond Street, London WC1N 1JH, United Kingdom. (Email: hoskoa{at}gosh.nhs.uk).

Objectives: To identify pretransplant factors associated with postprocedural right ventricular failure and the relationship between right ventricular failure and long-term survival in children.

Methods: Records were reviewed for children having heart transplantation from 2000 to 2006.

Results: Right ventricular failure was identified by clinical and echocardiographic parameters in 33/129 (25%) recipients: dilated cardiomyopathy in 14/90 (15%), congenital heart disease in 11/27 (41%), and restrictive cardiomyopathy in 8/12 (66%). In 9 of 12 (75%), known elevated (reactive) pulmonary vascular resistance progressed to right ventricular failure. In a further 23/117 (20%) recipients, pulmonary vascular resistance within predefined acceptable range progressed to right ventricular failure. Multiple logistic regression analyses indicated elevated pulmonary vascular resistance (odds ratio 12.30; 95% confidence interval 2.73, 55.32; P = .001) and primary diagnosis, restrictive cardiomyopathy (odds ratio 9.21; 95% confidence interval 2.07, 41.12; P = .004), and congenital heart disease (odds ratio 4.07; 95% confidence interval 1.36, 12.19; P = .012) were strongly associated with right ventricular failure, but duration of heart failure, pretransplant mechanical support, donor status, and ischemic times were not. Treatment included inhaled nitric oxide in 28 (84%), mechanical support in 10 (31%), hemofiltration in 13 (40%), and retransplantation in 2. A Cox multiple regression model including: primary diagnosis, right ventricular failure, and elevated pulmonary vascular resistance indicated that only the latter was independently linked with eventual mortality (hazards ratio 5.45; 95% confidence interval 1.36, 21.96; P = .017).

Conclusions: Primary diagnosis and pretransplant elevated reactive pulmonary vascular resistance are both linked to the evolution of right ventricular failure. Pulmonary vascular resistance assessment in end-stage heart failure is challenging; therefore, avoidance of right ventricular failure may not always be possible. Aggressive early treatment may mitigate the effects of right ventricular failure: pretransplant elevated pulmonary vascular resistance was independently associated with long-term survival, but right ventricular failure was not.

Abbreviations and Acronyms BSA = body surface area; CHD = congenital heart disease; DCM = dilated cardiomyopathy; ECMO = extracorporeal membrane oxygenation; iNO = inhaled nitric oxide; PVR = pulmonary vascular resistance; PVRI = pulmonary vascular resistance index; RCM = restrictive cardiomyopathy; RVF = right ventricular failure; TPG = transpulmonary gradient




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