Mortality and morbidity after retransplantation after primary heart transplant in childhood: an analysis from the registry of the International Society for Heart and Lung Transplantation

Background: Retransplantation for graft failure in the pediatric population is rare with reports of decreased survival compared with primary transplantation. Little is known about the risk factors for retransplantation or death after retransplantation; in addition, there is a paucity of data in the literature on transplant-related morbidities in this patient population. The purpose of this analysis of the registry of the International Society of Heart and Lung Transplant (ISHLT) was to describe outcomes after retransplantation as compared with primary transplantation, including identifying risk factors leading to retransplantation and both transplant-related morbidities and mortality after retransplantation.

Methods: Data from 1998 to 2010 were used to identify all patients whose primary transplantation was performed at <18 years of age. Of the 9,966 transplants reviewed, 9,248 primary transplants and 602 retransplants were analyzed.

Results: The median age for retransplantation was 14 (range 1 to 26) years, with the most common indication being allograft vasculopathy (58.5%). After retransplantation, early time-related risk of mortality was similar to that after primary transplantation (HR 1.07 [0.92 to 1.25], p = 0.40), but both late-phase time-related risk of mortality (HR 1.67 [1.40 to 1.99], p < 0.001) and requirement of an additional graft (HR 1.69 [1.18 to 2.43], p = 0.004) were higher. Long-term morbidities were significantly more common after retransplantation than with primary transplantation. These included allograft vasculopathy (HR 2.8 [2.37 to 3.38], p < 0.001), late rejection (HR 2.0 [1.65 to 2.40], p < 0.001) and late renal dysfunction (HR 2.6 [2.18 to 3.12], p < 0.001), but not cancer (HR 1.16 [0.74 to 1.82], p = 0.52). Numerous patient-, donor- and transplant-related risk factors were identified that increased both the risk of mortality and transplant-related morbidities after retransplantation.

Conclusions: Retransplantation after primary transplant in the pediatric age group, although feasible with similar early survival, is associated with decreased long-term survival and an increase in transplant-related morbidities. The results of this study highlight the ongoing challenges of managing patients after retransplant and also suggest some modifiable risk factors, for both the donor and recipient, which may improve survival and decrease the burden of morbidities.