• Heart transplant is a successive therapeutic option for treatment of end-stage of pediatric heart failure.
• Success depends on improved surgical technique, immunosuppression, organ preservation and follow-up.

Challenges in Pediatric Heart Transplant

• Congenital Heart diseases: previous thoracotomy and surgeries
• Higher risks of sensitized patients
• Complex cardiac anatomy (heterotaxia, interrupted IVC, double VCS, etc.)
• Higher risks of (arterial) pulmonary hypertension
• Mismatch size between donor-recipient (ideal mismatch weight 0,7 – 3)
• Doses of immunosuppression agents

Indications of Pediatric Heart Transplant

• Heart transplant is indicated for infants and children with end-stage cardiac disease that is irreversible, progressive, and has a limited life expectancy with no available or reasonable alternative medical or surgical therapy.
• The decision to list should take into account the progression of other organ dysfunction and pulmonary hypertension which would jeopardize (or preclude) future cardiac transplant consideration
• Supportive family (custodial) environment

Contraindications of Pediatric Heart Transplant

• Fixed pulmonary hypertension: PVRi >6 Woods units x m2 and non reactive to vasodilators or TPG > 15mmHg (PA mean – PCW mean)
• Severe or rapidly, progressive life-threatening neurologic or neuromuscular disorder
• Active sepsis or uncontrolled infection
• Irreversible, significant renal or hepatic failure (Unless patient are candidates for concomitant liver/kidney transplant)
• Active malignancy or recent malignancy with significant risk for recurrence
• Documented non-compliance with medications and medical follow-up that is not amenable to behavior or other supportive interventions

Workup for Heart Transplant

• Clinical evaluation; history and  physical examination, genetic test and to rule out neurological impairment
• Counselling to the family regarding the procedure and follow-up and acceptance of heart transplant for parents and patient (> 10 years)(clearance by social worker)
• Immunological evaluation – HLA study (Luminex)
• Infection screening – septic work-up
• Consultations: ID team (vaccination status), dental and pulmonologist assessment
• Others:
  • CBC, clotting profile, serologies (CMV, Toxoplasma, Hepatitis – A,B,C, VIH), PPD or quantiferon
  • EKG and echo
  • Abdominal Ultrasound + Doppler carotid and jugular veins