Cardiac retransplantation in children

William Mahle
Director of Clinical Research at Children’s Healthcare of Atlanta
Associate Professor of Pediatrics, Emory University School of Medicine
Atlanta, USA

For over 25 years cardiac transplantation has been employed in the treatment of children with advanced heart failure caused by cardiomyopathy or congenital heart disease. The most recent analysis of data from the International Society of Heart and Lung Transplantation (ISHLT) have reports an estimated half-life of over 13 years for children who have undergone heart transplantation.(1) Although survival has improved over the last two decades, it is likely that many of these children may ultimately be considered for retransplantation either as adolescents or young adults. In fact retransplantation now accounts for 7% of all pediatric heart transplants between.(2) This compares to 2% of all pediatric heart transplants in the preceding decade. Interestingly, retransplantation accounts for only 2% of adult heart transplants from 2003 to 2005, which is similar to data reported from the mid 1990s.(3;4) Given the potential for retransplantation to play an increasingly important role in children and young adults an understanding of the indications for retransplantation and the expected outcomes of retransplantation in this age group is warranted.
　Overall, cardiac retransplantation is associated with poorer outcome than primary transplantation. In children the median survival after retransplantation was 5.6 years as compared to 13.2 years after primary transplantation. Retransplantation for early graft failure has a particularly poor outcome. Given a 1-year survival of approximately 50 % for those retransplanted within 6 months of primary graft failure, the appropriateness of this strategy in light of the limited donor supply is questionable. The intermediate-term survival for all other retransplant patients is somewhat better, though the 5-year survival is just above 50%. When proceeding with retransplantation, one must be aware of particular risk factors in this population including a higher prevalence of renal dysfunction and allosensitization. There may a role for alternate immunosuppression strategies in the retransplant population.