Nancy McDonald

Impact of the 18th birthday on waitlist outcomes among young adults listed for heart transplant: A regression discontinuity analysis

BACKGROUND Patients listed for heart transplant after their 18th birthday purportedly wait longer to receive a donor heart compared with patients listed before their 18th birthday. It is unclear whether there is an actual difference in wait times and whether any difference in wait time is associated with lower likelihood of transplant and/or higher risk of mortality. METHODS Organ procurement and transplant network data were used to identify all patients listed for heart transplant between 2006 and 2014 within a 1-year period before and after their 18th birthday. The primary study end-point was the waiting time to receive a donor heart. Secondary end-points included the probability of transplant and waitlist mortality. Regression discontinuity analysis was used to analyze the effect of age on either side of the sharp cut-off value of age 18 years (6,574 days of life), when allocation of donor hearts transitions from the pediatric to adult allocation system. RESULTS A total of 360 patients met the study inclusion criteria, including 207 (57.5%) listed during the 12-month period before their 18th birthday under the pediatric allocation system, and 153 (42.5%) listed during the 12 months after their 18th birthday under the adult allocation system. The pediatric cohort was more likely to be listed Status 1A. Otherwise, the 2 groups shared similar baseline characteristics. Overall, patients listed after their 18th birthday waited 8.5 months longer to receive a transplant than adolescents listed before their 18th birthday (p = 0.01) and had a 47% lower probability of receiving a transplant (p = 0.001), but there was no difference in waitlist mortality (p = 0.37). CONCLUSIONS Patients listed for heart transplant shortly after their 18th birthday have significantly longer wait-times compared with patients listed shortly before their 18th birthday and a lower probability of transplant, but no significant difference in waitlist mortality. For medically fragile adolescents at high risk of death, birth date may be a relevant factor in the timing of heart transplant listing.

Impact of Heart Transplantation on the Functional Status of U.S. Children with End-Stage Heart Failure. Analysis of Data from the Organ Procurement and Transplantation Network.

Background: There are limited data describing the functional status (FS) of children after heart transplant (HT). We sought to describe the FS of children surviving at least 1 year after HT, to evaluate the impact of HT on FS, and to identify factors associated with abnormal FS post-HT. Methods: Organ Procurement and Transplantation Network data were used to identify all US children <21 years of age surviving ≥1 year post-HT from 2005 to 2014 with a functional status score (FSS) available at 3 time points (listing, transplant, ≥1 year post-HT). Logistic regression and generalized estimating equations were used to identify factors associated with abnormal FS (FSS⩽8) post-HT. Results: A total of 1633 children met study criteria. At the 1-year assessment, 64% were “fully active/no limitations” (FSS=10), 21% had “minor limitations with strenuous activity” (FSS=9); and 15% scored ⩽8. In comparison with listing FS, FS at 1 year post-HT increased in 91% and declined/remained unchanged in 9%. A stepwise regression procedure selected the following variables for association with abnormal FS at 1 year post-HT: ≥18 years of age (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.2–2.7), black race (OR, 1.5; 95% CI, 1.1–2.0), support with ≥inotropes at HT (OR, 1.7; 95% CI, 1.2–2.5), hospitalization status at HT (OR, 1.5; 95% CI, 1.0–2.19), chronic steroid use at HT (OR, 1.5; 95% CI, 1.0–2.2), and treatment for early rejection (OR, 2.0; 95% CI, 1.5–2.7). Conclusion: Among US children who survive at least 1 year after HT, FS is excellent for the majority of patients. HT is associated with substantial improvement in FS for most children. Early rejection, older age, black race, chronic steroid use, hemodynamic support at HT, and being hospitalized at HT are associated with abnormal FS post-HT.

Rehospitalization after pediatric heart transplantation: Incidence, indications, and outcomes.

We report the patterns of rehospitalization after pediatric heart transplant (Htx) at a single center. Retrospective review of 107 consecutive pediatric Htx recipients between January 22, 2007, and August 28, 2014, who survived their initial transplant hospitalization. The frequency, duration, and indications for all hospitalizations between transplant hospitalization discharge and September 30, 2015, were analyzed. A total of 444 hospitalization episodes occurred in 90 of 107 (84%) patients. The median time to first rehospitalization was 59.5 (range 1‐1526) days, and the median length of stay was 2.5 (range 0‐81) days. There were an average of two hospitalizations per patient in the first year following transplant hospitalization, declining to about 0.8 per patient per year starting at 3 years post‐transplant. Admissions for viral infections were most common, occurring in 93 of 386 (24%), followed by rule out sepsis in 61 of 386 (16%). Admissions for suspected or confirmed rejection were less frequent, accounting for 41 of 386 (11%) and 31 of 386 (8%) of all admissions, respectively. Survival to discharge after rehospitalization was 97%. Hospitalization is common after pediatric Htx, particularly in the first post‐transplant year, with the most frequent indications for hospitalization being viral illness and rule out sepsis. After the first post‐transplant year, the risk for readmission falls significantly but remains constant for several years.

Group visits in the pediatric heart transplant outpatient clinic

The “GVM” has emerged as an alternative to traditional individualized appointments in the ambulatory care setting. We hypothesized that group visits could successfully be utilized in a PHtx clinic. Seven patients, ages 1–18 yr old, and their families participated in a total of 11 group visits in lieu of individualized appointments. Patients were divided into two groups based on whether they were greater or less than one yr post‐transplant. Patient/provider satisfaction, medication adherence, and content retention were ascertained via questionnaires and free‐response tests. Total clinic throughput time, including per‐patient clinic utilization time, was compared to historical data. Six of seven patients completed the study with one dropout. Overall satisfaction ratings were 3.98 of 4 with all patients reporting that they would “strongly recommend” group visits to others. Health information retention tests demonstrated improvement between pre‐ and post‐tests in eight of nine (89%) of the group visits. Overall clinic utilization decreased by nearly 50% while providing 70 min of face‐to‐face time with the provider. Medication adherence neared 100% for all patients. The GVM can be successfully applied to the PHtx population with high patient and provider satisfaction, more face‐to‐face time, excellent content retention, and greatly improved clinic efficiency.

IVIG and graft coronary artery disease: a potentially deadly combination in pediatric heart transplant recipients.

Patient #1 was a five-yr-old girl who underwent OHT in 2007 for failed palliation of hypoplastic left heart syndrome (HLHS). She underwent desensitization with IVIG before transplant without complication. Following transplant, she continued to receive IVIG (400–600 mg/kg every 3–4 wk) after premedication with acetaminophen (15 mg/kg) and diphenhydramine (1 mg/kg), for hypogammaglobulinemia and recurrent pneumonias. She had no history of IVIG-related adverse events. Coronary angiography in November 2011 showed mild narrowing of the conal branch of the right coronary artery and mild pruning of the distal branches for which she was changed from mycophenolate mofetil to sirolimus. Follow-up cardiac catheterization and biopsy in November 2012 showed normal diastolic filling pressures, no evidence of cellular or antibodymediated rejection, and angiographically normal right dominant coronary arteries. An echocardiogram performed the same day revealed normal biventricular function (EF 60%). In January 2013, while receiving IVIG at home, she became acutely unresponsive; 911 was called, and she was transported to the closest ED, where resuscitative efforts were unsuccessful. Autopsy was not performed.