Outcome of Acute Graft Rejection Associated with Hemodynamic Compromise in Pediatric Heart Transplant Recipients

Abstract

We sought to analyze the outcome of hemodynamically significant acute graft rejection in pediatric heart transplant recipients from a single-center experience. Acute graft rejection remains a major cause of morbidity and mortality for patients who undergo orthotopic heart transplantation and has been associated with the severity of the rejection episode. A retrospective review of all children experiencing a hemodynamically significant rejection episode after orthotopic heart transplantation was performed. Fifty-three patients with 54 grafts had 70 rejection episodes requiring intravenous inotropic support. Forty-one percent of these patients required high-dose inotropic support, with the remaining 59% of patients requiring less inotropic support. Overall graft survival to hospital discharge was 41% for patients in the high-dose group compared to 94% in the low-dose group. Six-month graft survival in patients who required high-dose inotropes remained at 41% compared to 44% in the low-dose group. Hemodynamically significant acute graft rejection in pediatric heart transplant recipients is a devastating problem with poor short- and long-term outcomes. Survival to hospital discharge is dismal in patients who require high-dose inotropic support. In contrast, survival to discharge is quite good in patients who require only low-dose inotropic support; however, six-month graft survival in this group is low secondary to a high incidence of graft failure related to worsening or aggressive transplant coronary artery disease.

Antibody-Mediated Rejection in Cardiac Transplantation: Emerging Knowledge in Diagnosis and Management

“…[253][254][255][256][257] The recognition of AMR as a cause of graft dysfunction and graft vasculopathy in the pediatric heart transplant population is also increasing as the criteria for the diagnosis of AMR have been refined and surveillance for AMR has been more widely adopted. 78,258,259 In a large series (n=1217) reported by the Pediatric Heart Transplant Study Group, 15% of patients (<18 years of age) presented with severe acute ventricular dysfunction within 5 years of transplantation, and 30% of these had no or only mild evidence of cellular rejection (ISHLT grade 0 or 1R).…”

Left ventricular adaptation following orthotopic heart transplantation in children: A speckle tracking echocardiographic imaging study

“…6 The adaptive growth and changes in ventricular geometry secondary to immunosuppressant medications can affect the long-term performance of the transplanted heart. 8 Therefore, these patients need lifelong follow-up for surveillance of graft function and rejection. 7 Allograft rejection and coronary artery vasculopathy are long-term causes for LV dysfunction and remain the leading cause of morbidity in this patient population.…”

“…7 Allograft rejection and coronary artery vasculopathy are long-term causes for LV dysfunction and remain the leading cause of morbidity in this patient population. 8 Therefore, these patients need lifelong follow-up for surveillance of graft function and rejection.…”

Longitudinal Myocardial Deformation is Selectively Decreased After Pediatric Cardiac Transplantation: A Comparison of Children 1 Year After Transplantation With Normal Subjects Using Velocity Vector Imaging

“…Even in the absence of rejection, these myriad of variables introduce significant challenges for the evaluation of ventricular function in this population. Rejection, especially when associated with hemodynamic compromise, and CAV remain leading causes of morbidity and graft loss [20]. Therefore, improved detection of functional changes in the graft that could signify the presence of early acute graft rejection and CAV is critical for improved outcomes experienced by this challenging group of patients.…”