Lung Transplantation for Pulmonary Vascular Disease in Children: A United Network for Organ Sharing Analysis.

Pulmonary vascular disease (PVD) represents an important clinical indication for lung transplant (LTx) in infants, children, and adolescents. There is limited information on LTx outcomes in these patients. We explored LTx volumes and post-LTx survival in children with PVD compared to other diagnoses. The UNOS Registry was queried from 1989 to 2020 to identify first-time pediatric LTx recipients (< 18 yo). PVD was categorized as idiopathic pulmonary arterial hypertension (IPAH) and non-idiopathic arterial hypertension (non-IPAH) and compared to all other patients as other diagnoses. Univariate and multivariate regression models were performed. 984 pediatric LTx patients (593 before 2010 and 391 during/after 2010) were identified, of which 145 (14.7%) had PVD. There has been no significant change in annual rate of all LTxs over comparative eras. However, there has been a decrease in rate of LTxs for PVD patients. Children with PVD had similar survival to other LTx groups in the early era (p = 0.2) and the latter era (p = 0.9). Univariate Cox models, showed that LTx in patients with PVD was associated with a significantly less risk of mortality for children aged 6-11 years compared to younger and older cohorts (HR = 0.4 [0.17-0.98]; p = 0.045), whereas multivariate analysis showed a trend toward higher mortality in 11-17-year-olds (HR = 1.54 [0.97-2.45]; p = 0.06). For PVD patients, oxygen supplementation and ventilator support at LTx were associated with worse post-transplant survival (p = 0.029 and p = 0.01). There has been a decrease in LTx volume for pediatric patients with PVD in the modern era. Post-LTx outcomes for children with PVD are similar to those of other diagnoses in both eras, with children aged 6-11 years having the best survival. Given these findings, LTx should be considered for this patient population.

Changing racial and ethnic differences for lung transplantation in cystic fibrosis.

BACKGROUND: CFTR modulators, especially (elexacaftor/tezacaftor/ivacaftor), have positively impacted the CF population and quickly decreased LTx numbers. However, no study has investigated if this reduction is universal across all races/ethnicities. METHODS: Using the UNOS Registry, we explored the frequency/proportions of LTx in WNH and NW (Black, non-Hispanic/Hispanic-Latino/Asian-non Hispanic/American Indian-Alaskan Native-non-Hispanic/Native Hawaiian/Other Pacific Islander-non-Hispanic/Multiracial) in children and adults with CF in the US. RESULTS: Between 1990 and 2019, the annual mean (±SD) number of LTxs for children with CF was 23.2 (±7.7) compared to 5 in 2020 (p < .001) and in 2021 (p < .001). In adults from 1990 to 2019, the mean (±SD) number of LTxs performed was 144.9 (±73.5), which was significantly higher than 2020 (n = 73; p < .001) and 2021 (n = 45; p < .001). Comparing 1990-2019 to post-2019, the proportion of LTxs performed in both children and adults with CF has decreased from 50.5% (696/1378) to 16.4% (9/55) and from 12.1% (4773/39542) to 2.4% (118/5004), respectively. In WNH pediatric patients, the difference in the percentage of all LTx made up by CF patients between the two eras was 41.2% compared to NW patients where the difference was 11%. Similarly in adults, the difference between the two eras was 10.4% in WNH and 2.4% in NW patients. CONCLUSIONS: The recent reduction in LTx for the CF population has had less impact on the NW population in the US, so the continuation of optimal referrals for this group is needed.

Not all durations of preheart transplant mechanical ventilation portend inferior post-transplant survival in children.

BACKGROUND: Mechanical ventilation prior to pediatric heart transplantation predicts inferior post-transplant survival, but the impact of ventilation duration on survival is unclear. METHODS: Data from the United Network for Organ Sharing and Pediatric Health Information System were used to identify pediatric (<18 years) heart transplant recipients from 2003 to 2020. Patients ventilated pretransplant were first compared to no ventilation, then ventilation durations were compared across quartiles of ventilation (≤1 week, 8 days-5 weeks, >5 weeks). RESULTS: At transplant, 11% (511/4506) of patients required ventilation. Ventilated patients were younger, had more congenital heart disease, more urgent listing-status, and greater rates of nephropathy, TPN-dependence, and inotrope and ECMO requirements (p < .001 for all). Post-transplant, previously ventilated patients experienced longer ventilation durations, ICU and hospital stays, and inferior survival (all p < .001). Hospital outcomes and survival worsened with longer pretransplant ventilation. One-year and overall survival were similar between the no-ventilation and ≤1 week groups (p = .703 & p = .433, respectively) but were significantly worse for ventilation durations >1 week (p < .001). On multivariable analysis, ventilation ≤1 week did not predict mortality (HR 0.98 [95% CI 0.85-1.43]), whereas ventilation >1 week did (HR: 1.18 [1.01-1.39]). CONCLUSIONS: Longer pretransplant ventilation portends worse outcomes, although only ventilation >1 week predicts mortality. These findings can inform pretransplant prognostication.

Contemporary Outcomes of Heart Transplantation in Children with Heterotaxy Syndrome: Sub-Optimal Pre-Transplant Optimization Translates into Early Post-Transplant Mortality.

Patients with heterotaxy syndrome and congenital heart disease (CHD) experience inferior cardiac surgical outcomes. Heart transplantation outcomes are understudied, however, particularly compared to non-CHD patients. Data from UNOS and PHIS were used to identify 4803 children (< 18 years) undergoing first-time heart transplant between 2003 and 2022 with diagnoses of heterotaxy (n = 278), other-CHD (n = 2236), and non-CHD cardiomyopathy (n = 2289). Heterotaxy patients were older (median 5 yr) and heavier (median 17 kg) at transplant than other-CHD (median 2 yr and 12 kg), and younger and lighter than cardiomyopathy (median 7 yr and 24 kg) (all p < 0.001). UNOS status 1A/1 at listing was not different between groups (65-67%; p = 0.683). At transplant, heterotaxy and other-CHD patients had similar rates of renal dysfunction (12 and 17%), inotropes (10% and 11%), and ventilator-dependence (19 and 18%). Compared to cardiomyopathy, heterotaxy patients had comparable renal dysfunction (9%, p = 0.058) and inotropes (46%, p = 0.097) but more hepatic dysfunction (17%, p < 0.001) and ventilator-dependence (12%, p = 0.003). Rates of ventricular assist device (VAD) were: heterotaxy-10%, other-CHD-11% (p = 0.839 vs. heterotaxy), cardiomyopathy-37% (p < 0.001 vs. heterotaxy). The 1-year incidence of acute rejection post-transplant was comparable between heterotaxy and others (p > 0.05). While overall post-transplant survival was significantly worse for heterotaxy than others (p < 0.05 vs. both), conditional 1-year survival was comparable (p > 0.3 vs. both). Children with heterotaxy syndrome experience inferior post-heart transplant survival, although early mortality appears to influence this trend, with 1-year survivors having equivalent outcomes. Given similar pre-transplant clinical status to others, heterotaxy patients are potentially under risk-stratified. Increased VAD utilization and pre-transplant end-organ function optimization may portend improved outcomes.

Effect of ischemic time on pediatric heart transplantation outcomes: is it the same for all allografts?

BACKGROUND: Studies have shown that the optimal ischemia time (IT) threshold in pediatric heart transplantation (PHT) is up to 4 h, independent of other donor organ factors. The purpose of this study was to examine the relationship between IT and donor left ventricular ejection fraction (LVEF) and study their impact on PHT outcomes. METHODS: This is a retrospective cohort study of PHT (<18 years) identified in UNOS between January 2000 and March 2020. Post-transplantation survival analysis of patients receiving donor hearts with IT<4, 4-6, and >6 h was performed using Kaplan-Meier curves. Cohort was divided according to donor LVEF median value, and survival was analyzed. Cox regression was performed. RESULTS: Median LVEF was 65% in the study cohort (6669 PHT). Overall, IT>6 h was associated with worse survival compared to <4 h regardless of donor LVEF. For allografts with LVEF < 65%, IT = 4-6 h was associated with worse survival compared with IT < 4 h (p = .006) but had similar survival compared with IT > 6 h (p = .315). For allografts with LVEF ≥ 65%, IT = 4-6 h had similar survival compared with <4 h (p = .175) but improved survival compared with >6 h (p = .003). After adjusting for donor and recipient variables, Cox regression showed that IT = 4-6 h was not associated with increased mortality for LVEF ≥ 65%. CONCLUSIONS: The IT threshold of 4 h does not apply to all allografts. Recipients of hearts with LVEF≥65% can tolerate an IT up to 6 h without any detriment to survival. Routine acceptance of these donor hearts could mitigate longer waiting times and poor donor availability for many candidates.

External validation and comparison of risk score models in pediatric heart transplants.

BACKGROUND: Pediatric heart transplant (PHT) patients have the highest waitlist mortality of solid organ transplants, yet more than 40% of viable hearts are unutilized. A tool for risk prediction could impact these outcomes. This study aimed to compare and validate the PHT risk score models (RSMs) in the literature. METHODS: The literature was reviewed to identify RSMs published. The United Network for Organ Sharing (UNOS) registry was used to validate the published models identified in a pediatric cohort (<18 years) transplanted between 2017 and 2019 and compared against the Scientific Registry of Transplant Recipients (SRTR) 2021 model. Primary outcome was post-transplant 1-year mortality. Odds ratios were obtained to evaluate the association between risk score groups and 1-year mortality. Area under the curve (AUC) was used to compare the RSM scores on their goodness-of-fit, using Delong's test. RESULTS: Six recipient and one donor RSMs published between 2008 and 2021 were included in the analysis. The validation cohort included 1,003 PHT. Low-risk groups had a significantly better survival than high-risk groups as predicted by Choudhry (OR = 4.59, 95% CI [2.36-8.93]) and Fraser III (3.17 [1.43-7.05]) models. Choudhry's and SRTR models achieved the best overall performance (AUC = 0.69 and 0.68, respectively). When adjusted for CHD and ventricular assist device support, all models reported better predictability [AUC > 0.6]. Choudhry (AUC = 0.69) and SRTR (AUC = 0.71) remained the best predicting RSMs even after adjustment. CONCLUSION: Although the RSMs by SRTR and Choudhry provided the best prediction for 1-year mortality, none demonstrated a strong (AUC ≥ 0.8) concordance statistic. All published studies lacked advanced analytical approaches and were derived from an inherently limited dataset.

Reducing the wait: TCV can expand the donor pool for heart transplant candidates.

A 16-year-old with new-onset dilated cardiomyopathy underwent VAD placement, later complicated by low flow from outflow graft kinking. To expedite heart transplantation, TCV was calculated and compared with 141 normal patients pinpointing the upper weight threshold. He was transplanted 2 days later within the expanded weight range with no post-transplant complications.

Lung Transplantation for Bronchopulmonary Dysplasia.

BACKGROUND: Patients with bronchopulmonary dysplasia (BPD) have poor respiratory trajectories and are at increased risk of lung function decline with age. Lung transplant (LTx) is a possible treatment option for this growing patient population, but little has been published on LTx in this patient group. RESEARCH QUESTION: What are the characteristics of patients with BPD who are listed for LTx? How do waitlist and post-LTx outcomes for BPD compare with LTx for other diagnoses? STUDY DESIGN AND METHODS: The United Network for Organ Sharing (UNOS) registry was queried for patients of all ages listed for or who underwent LTx (2000-2020). Descriptive analysis, waitlist outcomes, and post-LTx survival at 1, 5, and 10 years were assessed comparing patients with BPD vs LTx patients with other diagnoses. Post-LTx survival for patients with BPD born in the pre-surfactant era (pre-SE, before 1990) and those born in the post-surfactant era (post-SE) was compared. Propensity score matching was performed to control for the risk factors and match patients with BPD with other LTx patients on a 1:1 ratio. RESULTS: BPD was reported in 65 patients, of whom 32 (49.2%) underwent LTx. Patients with BPD at listing were younger than those with other diagnoses (median age, 21 [interquartile range, 5-31] years vs 57 [45-63] years; P < .001), and more were likely to receive mechanical ventilation at listing (23% vs 3.7%; P < .001). Patients with BPD had an FEV1 of 17% compared with 34% predicted in other patients (P = .002). Patients with BPD had an overall similar post-LTx survival compared with patients with other diagnoses (P = .106), even following propensity score matching (P = .41). INTERPRETATION: LTx for BPD has increased over the last 20 years. Patients with BPD have similar post-LTx outcomes compared with those of other patient populations in the modern era. Thus, LTx could be considered for patients with BPD experiencing progressive respiratory deterioration.

In the era of outpatient ventricular assist devices, is it time to reconsider the practice of bridging older children to transplant on outpatient inotropes?

OBJECTIVE: Ventricular assist devices (VADs) and inotropes are feasible modalities to bridge children to heart transplant (HT) in outpatient settings. However, it is unclear which modality yields superior clinical status at HT and posttransplant survival. METHODS: The United Network for Organ Sharing was used to identify patients aged 18 years or younger, weighing >25 kg, from 2012 to 2022 who were outpatients at HT (n = 835). Patients were grouped by bridging modality at HT: VAD (n = 235 [28%]), inotropes (n = 176 [21%]), or neither (no support) (n = 424 [50%]). RESULTS: VAD patients were of similar age (P = .260) but heavier (P = .007) and more likely to have dilated cardiomyopathy (P < .001) than their inotrope counterparts. VAD patients had similar clinical status at HT but superior functional status (performance scale >70%) (59% vs 31%) (P < .001). Overall posttransplant survival in VAD patients (1-year and 5-year survival, 97% and 88%, respectively) was comparable to patients with no support (93% and 87%, respectively) (P = .090) and those on inotropes (98% and 83%, respectively) (P = .089). One-year conditional survival was superior for VAD vs inotrope (2-year and 6-year survival, 96% and 91%, respectively vs 97% and 79%, respectively) (P = .030) and 5-year conditional survival for VAD patients was superior to inotrope (7-year and 10-year survival, 100% and 100%, respectively vs 100% and 88%, respectively) (P = .022) and no support (100% and 83%, respectively) (P = .011). CONCLUSIONS: Consistent with prior studies, short-term outcomes for pediatric patients bridged to HT in the outpatient setting with VAD or inotropes is excellent. However, compared with outpatients bridged to HT on inotropes, outpatient VAD support allowed for better functional status at HT and superior late posttransplant survival.

Body mass index percentage and survival in pediatric patients listed for lung transplantation: A modern-era multi-institutional analysis.

BACKGROUND: Prior studies suggest that being underweight by body mass index percentiles (BMI%) or thinness grade did not affect post-transplant survival in pediatric lung transplant (LTx) recipients regardless of cystic fibrosis (CF) or non-CF diagnosis. Graft and overall survival from the time of listing was instead evaluated based on listing BMI%, the current standard of practice for BMI definitions in pediatrics, to ascertain the impact of a "severely low" subcategory. METHODS: The UNOS registry was queried for children listed for LTx (aged 2 to <18 years) from January 1986 to March 2020. BMI% at listing and transplant were calculated per CDC guidelines according to age in years, sex, and reported BMI%. Patients were divided by listing BMI%: severely low (<3rd), low (3-<5th), normal (5-<85th), overweight (85-<95th), and obese (≥95th). Kaplan-Meier curves were generated to assess differences in overall survival since listing based on BMI% classes. Cox proportional-hazards models were developed to assess risk factors for overall and graft survival, including listing BMI%, transplant listing era (≥2005), and listing age, by reporting hazard ratios (HR). RESULTS: Listing BMI% was calculable for 1,876 patients. The proportion of patients with CF differed significantly between BMI% groups (p < 0.001). Patients listed with a non-CF diagnosis comprised 34% of those in the severely low category, and 88% of those listed with an obese BMI%. Compared to patients with a normal listing BMI%, the cohort with severely low BMI% had worse overall survival regardless of LTx (p = 0.009) and graft survival (p = 0.034). Compared to patients with a low BMI%, those with a severely low BMI% had significantly poorer graft survival as well (p = 0.040). Mean graft survival was not significantly different between groups that remained at listing BMI% vs those that improved in category despite an overall small sample size. Independent predictors of poorer survival from the time of listing include severely low vs low-normal BMI% (HR = 1.20) and listing age (HR = 1.02). CONCLUSION: The proportion of children listed at severely low BMI% has steadily decreased with time, yet pediatric LTx candidates listed with a severely low BMI% had poorer graft and overall survival compared to those of normal BMI%. Severely low listing BMI% was an independent prognostic factor for higher mortality risk from the time of placement on the waitlist. BMI% may be a modifiable target for improving survival regardless of transplantation.

Lung Transplantation for Pulmonary Vascular Disease in Children: A United Network for Organ Sharing Analysis.

Background: Pulmonary vascular disease (PVD) represents an important clinical indication for lung transplant (LTx) in infants, children, and adolescents. There is limited information on LTx outcomes in these patients. We explored LTx volumes and post-LTx survival in children with PVD compared to other diagnoses. Methods: The UNOS Registry was queried from 1989-2020 to identify first-time pediatric LTx recipients (<18 yo). PVD was categorized as idiopathic pulmonary arterial hypertension (IPAH) and non-idiopathic arterial hypertension (non-IPAH) and compared to all other patients as other diagnoses. Univariate and multivariate regression models were performed. Results: 984 pediatric LTx patients (593 before 2010 and 391 during/after 2010) were identified, of which 145 (14.7%) had PVD. There has been no significant change in annual rate of all LTxs over comparative eras. However, there has been a decrease in rate of LTxs for PVD patients. Children with PVD had similar survival to other LTx groups in the early era (p=0.2) and the latter era (p=0.9). Univariate Cox models, showed that LTx in patients with PVD was associated with a significantly less risk of mortality for children aged 6-11 years compared to younger and older cohorts (HR=0.4 [0.17-0.98];p=0.045), whereas multivariate analysis showed a trend towards higher mortality in 11-17-year-olds (HR=1.54 [0.97-2.45];p=0.06). For PVD patients, oxygen supplementation and ventilator support at LTx were associated with worse post-transplant survival (p=0.029 and p=0.01). Conclusions: There has been a decrease in LTx volume for pediatric patients with PVD in the modern era. Post-LTx outcomes for children with PVD are similar to those of other diagnoses in both eras, with children aged 6-11 years having the best survival. Given these findings, LTx should be considered for this patient population.

Impact of Size Matching on Survival Post Heart Transplant in Infants: Estimated Total Cardiac Volume Ratio Outperforms Donor-Recipient Weight Ratio.

PURPOSE: Cardiac volume-based estimation offers an alternative to donor-recipient weight ratio (DRWR) in pediatric heart transplantation (HT), but has not been correlated to post-transplant outcomes We sought to determine whether estimated Total Cardiac Volume (eTCV) ratio is associated with HT survival in infants. METHODS: The UNOS database was used to identify infants (age:<1year) who received HT in 1987-2020. Donor and recipient eTCV were calculated from weight using previously published data. Patient cohort was divided according to the significant range of eTCV ratio; characteristics and survival were compared. RESULTS: 2845 infants were identified. Hazard ratio with cubic spline showed prognostic relationship of eTCV ratio and DRWR with the overall survival. The cut-point method determined an optimal eTCV ratio range predictive of infant survival was 1.05-1.85 whereas no range for DRWR was predictive. 75.6% patients had an optimal TCV ratio, while 18.1% were in the lower (LR) and 6.3% in the higher (HR) group. Kaplan-Meier analysis showed better survival for patients within the optimal vs LR (p=0.0017), and a similar significantly better survival when compared to HR (p=0.0053). The optimal eTCV ratio group (n=2151) had DRWR ranging from 1.09-5; 34.3% had DRWR 2-3, and 5.0% DRWR>3. CONCLUSION: Currently, an upper DRWR limit has not been established in infants. Therefore, determining the optimal eTCV range is important to identifying an upper limit that significantly predicts survival benefit. This finding suggests a potential increase in donor pool for infant recipients since over 40% of donors in the optimal eTCV range includes DRWR values>2 that are traditionally not considered for candidate listing.

Center volume effect on acute cellular rejection and outcomes in pediatric lung transplant recipients.

BACKGROUND: Acute cellular rejection (ACR) is common after lung transplant (LTx). We sought to determine if transplant center volume affected ACR-related outcomes in children after LTx. METHODS: The United Network for Organ Sharing (UNOS) Registry was queried for patients <18-years-of-age who underwent LTx 1987-2020. Cohorts were children who survived the first-year post transplant and were treated for ACR within that first year (ACR group) and those not treated for ACR (non-ACR). LTx center volume was defined as: high volume center (HVC) (>5LTxs/year), medium volume center (MVC) (>1≤5 LTxs/year), and low volume center (LVC) (≤1LTxs/year). RESULTS: 1320 patients were enrolled into the study; 269 (20.4%) did not experience ACR. The ACR cohort was older (median 14 [11-16] vs 13 [7-16] years, p < 0.001), female (65.3% vs 57.3%, p = 0.016), had cystic fibrosis (62.3% vs 45.5%, p < 0.001), and had a higher lung allocation score (37.3 [34.6-47.8] vs 35.8 [33-42.6], p = 0.029). The ACR cohort trended (p = 0.06) towards lower survival at 5-year (37% vs 47%) and 10-year (25% vs 34%) post-LTx. Among children at HVCs, ACR occurred in 17% of recipients (n = 98/574), compared to 18.5% (n = 73/395) at MVCs and 27% (n = 100/369) at LVCs. Children treated for ACR at HVCs had higher survival than LVCs at 5-years (52% vs 29%) and 10-years (36% vs 15%) (p < 0.001) but similar survival to MVCs at 5-years (52% vs 43%) and 10-years (36% vs 24%) (p = 0.081). No survival differences were detected in MVCs vs LVCs (p = 0.14). CONCLUSIONS: ACR treated within the first post-LTx year influence survival of children. ACR incidence was lowest at higher volume centers whereas post-ACR treatment survival outcomes were also superior.

Lung Transplantation Advanced Prediction Tool: Determining Recipient's Outcome for a Certain Donor.

BACKGROUND: Many risk-prediction models for lung transplantation are centered on recipient characteristics and do not account for impact of donor and transplant-related factors or only examine short-term outcomes (eg, predicted 1-y survival). We sought to develop a comprehensive model guiding recipient-donor matching. METHODS: We identified double lung transplant recipients (≥12 y old) in the United Network for Organ Sharing Registry (2005-2020) to develop a risk scoring tool. Cohort was divided into derivation and validation sets. A total of 42 recipient, donor, and transplant factors were included in the analysis. Lasso method was used for variable selection. Survival was estimated using Cox-proportional hazard models. An interactive web-based tool was developed for clinical use. RESULTS: A derivation cohort (n = 10 660) informed the model with 13-recipient, 4-donor, and 2-transplant variables. Adjusted risk scores were computed for every transplant and grouped into 3 clusters. Model-estimated survival probabilities were similar to the observed in the validation cohort (n = 4464) for all clusters. The mortality increases for medium- and high-risk groups was similar in both derivation and validation cohorts (C statistics for 1-, 5-, and 10-y survival were 0.67, 0.64, and 0.72, respectively). The web-based application estimated 1-, 5-, 10-y survival and half-life for low- (92%, 73%, 52%; 10.5 y), medium- (89%, 62%, 38%; 7.3 y), and high-risk clusters (85%, 52%, 26%; 5.2 y). CONCLUSIONS: Advanced methods incorporating machine/deep learning led to a risk scoring model (including recipient, donor, and transplant factors) and a web-based clinical tool providing short- and long-term survival probabilities for recipient-donor matches. This will enable risk-based matching that could improve utilization of and benefit from a limited donor pool.

More Than 400 Uses of an Intestinal Submucosal Extracellular Matrix Patch in a Congenital Heart Program.

BACKGROUND: Repair of complex congenital heart disease frequently requires use of a patch as an anatomic substitute. The study's aim is to evaluate the use, effectiveness, and safety of using small intestine submucosal extracellular matrix (SIS-ECM) patches in a congenital cardiac surgery program. METHODS: This is a single-center, retrospective, cohort study of surgeries using SIS-ECM between 2012 and 2019. The SIS-ECM data were categorized by use and type (four-ply and two-ply). All reinterventions and complications were reviewed by an independent surgeon, a practicing congenital heart surgeon, and a pediatric cardiologist. RESULTS: In all, 408 SIS-ECM patches were used in 309 patients (188 male, 121 female; median age 8.5 months). Use of the patches consisted of 314 arterioplasties (77%), 22 venoplasties (5.4%), 63 intracardiac repairs (15.4%), and 9 valve repairs (2.2%). The most common use was for pulmonary artery repair (n = 181; 44.4%). Median follow-up time was 3.9 years (range, 3 days to 7.4 years). Ten patches (2.5%) required surgical reintervention (2 in the first 30 days and 5 in the first year) and 27 (6.6%) required percutaneous reinterventions (2 in the first 30 days and 22 in the first year). Between four-ply (n = 376) and two-ply (n = 32) SIS-ECM, the rate of surgical (2.1% [n = 8] vs 6.3% [n = 2], P = .18) or percutaneous reinterventions (6.4% [n = 24] vs 9.4% [n = 3], P = .46) was not different. There were no deaths related to the SIS-ECM patch or reports of calcification. CONCLUSIONS: The SIS-ECM is a viable patch option that can be used in various cardiac and vascular reconstructive surgeries with low risk of failure and calcification. Long-term, positive outcomes may be maximized by using consistent techniques and understanding the appropriate applications of the patch.

Palliated Hypoplastic Left Heart Syndrome Patients Experience Superior Waitlist and Comparable Post-Heart Transplant Survival to Non-Single Ventricle Congenital Heart Disease Patients.

Congenital heart disease (CHD) is a well-established risk factor for inferior waitlist and post-heart transplant survival in children. Differences in outcomes between CHD subgroups are understudied. The present study compared outcomes for palliated hypoplastic left heart syndrome (HLHS) patients to other non-single ventricle CHD (non-SVCHD) and non-CHD patients. United Network for Organ Sharing was used to identify children (age < 18) listed for heart transplant in the United States between 2016 and 2021. CHD sub-diagnoses were only available for United Network for Organ Sharing status 1a after 2015, thereby defining the cohort. Waitlist outcomes were studied using competing-risk time-to-event analysis for transplantation, mortality/decompensation, and alive-on-waitlist. Multivariable Cox proportional hazards regression analyses were used to identify factors associated with inferior post-transplant survival. Patients included: palliated-HLHS (n = 477), non-SVCHD (n = 686), and non-CHD (n = 1261). At listing, Palliated-HLHS patients were older than non-SVCHD (median 2-year [IQR 0-8] vs median 0-year [0-3], respectively) and younger than non-CHD (median 7-year [0-14]) (P < 0.001 vs both), and were more likely to be white (P < 0.01 vs both). Upon time-to-event analysis, rates of waitlist mortality/decompensation rates were greater among non-SVCHD than palliated-HLHS. Post-transplant survival was comparable between palliated-HLHS and non-SVCHD (P = 0.920) but worse compared to non-CHD (P < 0.001). Both palliated-HLHS (HR 2.40 [95% CI 1.68-3.42]) and non-SVSCHD (2.04 [1.39-2.99]) were independently associated with post-transplant mortality. Palliated-HLHS patients with heart failure experience significantly worse post-transplant outcomes than non-CHD but, compared to other CHD patients, experience superior waitlist and comparable post-transplant survival. While a high-risk cohort, HLHS patients can achieve gratifying waitlist and post-transplant survival.

Heart-kidney listing is better than isolated heart listing for pediatric heart transplant candidates with significant renal insufficiency.

OBJECTIVES: Significant renal insufficiency is identified as a risk factor for post-transplantation mortality in pediatric heart transplant recipients. This study evaluates simultaneous heart-kidney transplantation listing outcomes compared with heart transplant for pediatric candidates with significant renal insufficiency. METHODS: The United Network for Organ Sharing registry was searched for patients (January 1987 to March 2020) who were simultaneously listed for a heart-kidney transplantation or for heart transplant with significant renal insufficiency at the time of listing. Significant renal insufficiency was defined as needing dialysis or having a low estimated glomerular filtration rate (<40 mL/min). Survival was calculated using Kaplan-Meier analysis. RESULTS: A total of 427 cases were identified; 109 were listed for heart-kidney transplantation, and 318 were listed for heart transplant alone. Median time on the waitlist was 101 days (interquartile range, 28-238) for heart-kidney transplantation listings compared with 39 days (14-86) and 23.5 days (6-51) for heart transplant recipients with a low estimated glomerular filtration rate (P = .002) or on dialysis (P < .001), respectively. Of all heart-kidney transplantation listings, 66% (n = 71) received a transplant compared with 54% (n = 173) of heart transplantation with significant renal insufficiency (P = .005) with a mean survival of 14.6 years (12.7-16.4 years) for heart transplant without significant renal insufficiency at transplantation and 7.6 years (5.4-9.9 years) for heart transplant with significant renal insufficiency at transplantation. At 1 year after listing, 69% of heart-kidney transplantation listed recipients were alive, compared with 51% of heart transplant listed recipients (P = .029). Heart-kidney transplantation recipients had better 1-year post-transplantation survival (86%) than heart transplantation with significant renal insufficiency at transplant (66%) (P = .001). There was no significant difference in the 1- and 5-year survivals of those undergoing heart transplantation listed with significant renal insufficiency but no significant renal insufficiency at the time of transplant (89% and 78%) and heart-kidney transplantation recipients (86% and 81%; P = .436). CONCLUSIONS: Pediatric candidates with significant renal insufficiency listed for heart-kidney transplantation have superior waitlist and post-transplantation outcomes compared with those listed for heart transplant alone. Patients with significant renal insufficiency should be listed for heart-kidney transplantation, however; if their renal function improves significantly, heart transplant alone appears judicious.

Comparing donor and recipient total cardiac volume predicts risk of short-term adverse outcomes following heart transplantation.

INTRODUCTION: In pediatric heart transplantation, donor: recipient weight ratio (DRWR) has long been the sole metric for size matching. Total cardiac volume (TCV)-based size matching has emerged as a novel method to precisely identify an upper limit of donor organ size of a heart transplant recipient while minimizing the risk of complications from oversizing. The clinical adoption of donor: recipient volume ratio (DRVR) to prevent short-term adverse outcomes of oversizing is unknown. The purpose of this single-center study is to determine the relationship of DRWR and DRVR to the risk of post-operative complications from allograft oversizing. METHODS: Recipient TCV was measured from imaging studies and donor TCV was calculated from published TCV prediction models. DRVR was defined as donor TCV divided by recipient TCV. The primary outcome was short-term post-transplant complications (SPTC), a composite outcome of delayed chest closure and prolonged intubation > 7 days. A multivariable logistic regression model of DRWR (cubic spline), DRVR (linear) and linear interaction between DRWR and DRVR was used to examine the probability of experiencing a SPTC over follow-up as a function of DRWR and DRVR. RESULTS: A total of 106 transplant patients' records were reviewed. Risk of the SPTC increased as DRVR increased. Both low and high DRWR was associated with the SPTC. A logistic regression model including DRWR and DRVR predicted SPTC with an AUROC curve of 0.74. [95% CI 0.62 0.85]. The predictive model identified a "low-risk zone" of donor-recipient size match between a weight ratio of 0.8 and 2.0 and a TCV ratio less than 1.0. CONCLUSION: DRVR in combination with DRWR predicts short-term post-transplant adverse events. Accepting donors with high DRWR may be safely performed when DRVR is considered.

The psychometric properties of the Ages and Stages Questionnaires-3 in Arabic: Cross-sectional observational study.

BACKGROUND: Screening for developmental delay is recommended for pediatricians, yet validated screening tools in Arabic are scarce. AIMS: Assess the reliability, validity, sensitivity and specificity of the Arabic ASQ-3 in detecting developmental delays in children aged 4-33 months. STUDY DESIGN: Cross-sectional observational study. SUBJECTS: A sample of 491 children from all Lebanese governorates from five age groups (4, 10, 18, 27 and 33 months). OUTCOME MEASURES: Internal consistency using Cronbach's alpha (Cα), convergent construct validity using Pearson Correlation Coefficient (CC) comparing ASQ-3 in Arabic (A-ASQ-3) to Bayley scale for infant development (BSID-III) scores were computed. A subset sample (n = 35) underwent assessment with BSID-III for convergent validity, and sensitivity and specificity. A-ASQ-3 scores were compared to the US mean cutoff scores. RESULTS: Subjects' mean age was 17.75 ±â€¯10.6 months. Cα was 0.85; Pearson CC showed positive moderate correlation between A-ASQ-3 gross and fine motor scores and BSID-III composite motor scores (r = 0.42, p = 0.002; r = 0.39, p = 0.004, respectively); and positive moderate correlation between A-ASQ-3 problem solving and BSID-III cognitive scores (r = 0.43, p = 0.001). A-ASQ-3 had 100% sensitivity and 50% specificity for cognitive scores; 60% sensitivity and 70% specificity for motor scores. CONCLUSION: A-ASQ-3 has adequate reliability and validity for the tested age groups. It is plausible that this would hold true for the rest of the questionnaires. Further testing is needed to make the five clusters more aligned with the US sample scores and to improve the sensitivity and specificity.