Pediatric Cardiac Transplantation Using Hearts Previously Refused for Quality: A Single Center Experience

Abstract

Pediatric donor hearts are regularly refused for donor quality with limited evidence as to which donor parameters are predictive of poor outcomes. We compare outcomes of recipients receiving hearts previously refused by other institutions for quality with the outcomes of recipients of primarily-offered hearts. Data for recipients aged ≤ 18 and their donors were obtained. Specific UNOS refusal codes were used to place recipients into refusal and non-refusal groups; demographics, morbidity, and mortality were compared. Kaplan-Meier analysis with log-rank test was used to determine differences in graft survival. A multivariable Cox proportional hazards model was constructed to determine independent risk factors for post-operative mortality. From 7/1/2000-4/30/2011, 182 recipients were transplanted and included for analysis. 130 received a primarily-offered heart; 52 received a refused heart. No difference in post-operative complications or graft survival between the two groups (p=0.355) was found. Prior refusal was not an independent risk factor for recipient mortality. Analysis of this large pediatric cohort examining outcomes with quality-refused hearts shows that in-hospital morbidity and long-term mortality for recipients of quality-refused hearts is no different than recipients of primarily-offered hearts, suggesting that donor hearts previously refused for quality are not necessarily unsuitable for transplant and often show excellent outcomes.

Donor selection in the modern era

“…This is especially true in pediatric heart transplantation, where donor acceptance criteria tend to be more stringent. Nevertheless, an analysis of recipient outcomes at a high-volume pediatric heart transplant center showed that in-hospital morbidity and long-term mortality in recipients of donor hearts refused by other centers for quality concerns were no different than outcomes in recipients of primarily offered hearts (17). More recently, an analysis of the UNOS registry showed that use of adolescent donor hearts refused by pediatric centers resulted in excellent outcomes in adult recipients (18).…”

Outcome of pediatric heart transplantation in blood culture positive donors in the United States

“…Demographic characteristics of BCPD and NBCPD were similar with respect to gender, weight, BMI, ABO blood type, and hepatitis B and C status. BCPD were more likely to be older (11)(12)(13)(14)(15)(16)(17)(18)…”

“…One of the many ways to increase the availability of organs is using high‐risk donors or suboptimal organs. Pediatric studies using high‐risk donors, donors previously refused and donors with depressed ventricular function have been successful …”

Pediatric heart transplantation from an influenza B–positive donor

“…Two of the most commonly utilized UNOS refusal codes are 830 (unacceptable donor “age or quality”) and 837 (“organ‐specific donor issue”). Easterwood et al demonstrated no difference in graft survival following utilization of donor hearts previously refused using these codes despite a higher incidence of positive blood cultures, Public Health Service increased‐risk status, cardiac arrest, and cardiopulmonary resuscitation. Similarly, a recently derived Pediatric Heart Donor Assessment Tool demonstrated acceptable predictive capabilities for 1‐ and 5‐year post‐transplant morality, with ischemic times greater than 4 hours, donor cerebrovascular accident, donor‐to‐recipient height ratios >1.2, severe renal insufficiency, and left ventricular ejection fraction of <50% as the only variables that persisted in multivariate analyses .…”