The Pediatric Heart Transplant: Little People, Big Concerns

Only 1 in 6 heart transplants is done in a child, which means that globally, approximately 600 children undergo this procedure annually (although 11,000 children are included on the International Society for Heart and Lung Transplantation registry and awaiting transplant). Clearly, pediatric heart transplant is a rare occurrence. A paper published in the Journal of Thoracic Disease makes the case for performing pediatric heart transplants in specialized centers and addressing factors unique to the pediatric patient.

Written by a transplant team from Switzerland, this paper indicates that optimal short- and long-term survival must include good quality of life. It also emphasizes difference between pediatric heart transplant and heart transplant in adults. The leading indication for heart transplant in children is congenital heart disease (CHD), but in 2013, 54% of pediatric heart transplant patients had CHD compared to 81% in the 1990s as staged surgery (the Norwood procedure) has become the standard of care and reduced the need for transplant.

Survival has lengthened with more experience and better technique, and children tend to survive longer than adults. Average survival is 19.7 years for infants, 16.8 years for recipients aged 1 to 5 years, and 14.5 years for recipients between 6 and10 years of age. Nine percent of teenage heart transplant recipients are listed for re-transplantation.

An interesting note is that globally, 2% of pediatric heart transplant recipients overall are listed for re-transplantation but in the US, that number is 6%, a statistic that the authors do not attempt to explain.

A critical factor to survival is a strong support system and a family willing to restructure their lives around the patient’s new needs.

Like adults, children face long waits on transplant waitlists, but for them, the discrepancy between need and suitable donor organs is greater. Adults are likely to use ventricular assist devices (VADs) while they wait, but few VADS are available, especially for babies and toddlers.

These authors also describe unique pediatric anatomy and physiology that creates challenges and increases surgical complexity. They emphasize that children need a well-organized and educated pediatric team that includes cardiologists, intensivists, and a highly skilled surgeon.