Editor
Courtney A. Hardy, MD
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Co-Editors
Mark Twite, MD, BCh
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Stuart R. Hall, MD
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President's Message

Letter from the Editor

STS-CCAS Database Update

Brief Update: Status of Pediatric Heart Transplantation

Pediatric Heart Transplant in Canada

Pediatric Heart Transplant in the UK

LITERATURE REVIEWS

The Registry of the International Society for Heart and Lung Transplantation:  Fifteenth Pediatric Heart Transplantation Report – 2012

Heart Transplantation in the UK

By Jonathan H Smith
Consultant in Paediatric Cardiothoracic Anaesthesia and Intensive Care
Freeman Hospital
Newcastle upon Tyne
UK

Paediatric cardiac transplantation in the United Kingdom is done in either Freeman Hospital in Newcastle or Great Ormond Street Hospital in London. Patients come from the regions, Scotland and the Republic of Ireland. Approximately 40 grafts are performed each year. The international trend to support children with heart failure with a mechanical device is reflected in the UK experience as the majority of recipients now come from the VAD programme. Children are most often between one and two years of age and weigh about 10Kg. Inevitably, this places them on the cusp between the two smaller sizes of the Berlin heart VAD, a new intermediate size of ventricle is available now.

There is a relative donor shortage. We know that for weights less than 20Kg, the waiting time may be in excess of 40 days and as long as 80 days. As a result, the child is exposed to a prolonged period of mechanical assist with the side effects of bleeding, thrombo-embolism or device malfunction. The stroke rate in our population on VAD is about 30% and these events can be devastating.

Attacking the donor shortage is difficult. There are three tactics used. The uptake of ABO incompatible heart transplant has been good and all infants with low anti A or Anti B titres (<1:16) are considered for this and outcomes are just as good as matched donations in this age group. The UK government has promoted organ donation aggressively and re-organized donation services to improve the number of organs offered.  Yet donation after brain death  (DBD) is less frequent and as yet, donation after cardiac death (DCD) has not allowed cardiac donation. The UK paediatric cardiac group is trying to influence attitudes and develop protocols that would allow suitable paediatric DCD donors to become cardiac donors. In the same vein we are now (within the last six months) accepting what would previously have been considered unacceptable hearts for implantation and promoting recovery in situ in the recipient by the elective use of ECMO in the recipient to forestall early and lethal primary graft failure.

The maturity of hypoplastic left heart surgery and the possibility of mechanical assist allowing longer waiting times has led to an increase in the referral of children with single ventricle physiology for transplant assessment. The support of children with this anatomy is very challenging and has a high mortality.  We have changed the way we seek consent for treatment. We now go into painstaking detail of the strategy for support, the likelihood of devastating complications and the occasional need for withdrawal of therapy should transplantation become impossible because of intercurrent organ failure.

Adults with congenital heart disease are now more likely to be referred for cardiac transplantation and occasionally VAD therapy. They have all the problems of the children without any of the immunological elasticity and some exhibit complications from previous surgery. They are demanding of MDT and clinical time and still have a high morbidity and mortality. The failing Fontan is the exemplar of this. Most are now done at the Freeman Hospital. Our own strategy is changing in that we now try to list these young adults earlier than in the past and so increase their opportunity of getting a suitable organ.

Given these developments, anaesthetists are becoming more adept at looking after children on mechanical assist; even more aware of the devastating problems that result from infection or venous thrombosis, which preclude proper access. We are coordinating a more complex transplant course because of the difficult patient population and the complicated peri-operative care plans that they require.

References

1. Botha P, Solana R, Cassidy J et al. The impact of mechanical circulatory support on outcomes in paediatric heart transplantation. Eur J Cardiothorac Surg. 2013
2. Cassidy J, Haynes S, Kirk R et al. Changing patterns of bridging to heart transplantation in children. J Heart Lung Transplant. 2009;28:249-254.