eComment. Paediatric cardiac transplantation - Better outcome, more challenges and novel alternatives

In this article Raissadati et al. report long-term outcome of 68 paediatric cardiac transplant recipients in Finland between 1991 and 2014 [1].

Our colleagues have to be congratulated for the highly competitive short- and long-term outcome of their overall therapeutic regime in a low volume center for paediatric cardiac transplantation. The authors report a 30-day mortality of 10% along with 68% and 65% survival at 10 and 15 years, respectively. Cardiomyopathy (57%) was the leading indication followed by a relatively high proportion of patients with congenital heart disease (CHD) (43%). These two groups revealed similar long-term survival. Five of the six early deaths occurred from the group with CHD in their initial experience in the 1990s. There were six patients only in the cardiomyopathy group who had been treated with a ventricular assist device (VAD). Even when VADs has been effectively and safely used in the paediatric population in bridging patients to cardiac transplantation we are still in need for the ideal device. Early decision and liberal institution of VADs has been reported to produce excellent survival with the device and following cardiac transplantation [2].

Despite chronic shortage of donor organs cardiac transplantation is still the gold standard for the treatment of children with end-stage heart failure. Reports from high volume centers failed to show a long-term difference in survival of patients with cardiomyopathy versus CHD after cardiac transplantation. However, in these studies we have to note that higher early mortality is observed in patients with CHD [3]. Since 1988 in 206 paediatric heart transplantations (8 re-transplantations) our group has a 10-year survival of 76% in patients with congenital heart disease and 83% with cardiomyopathy most recently [4]. Overall survival is 70% at 20 years. The rate of severe coronary artery vasculopathy (CAV) is 5% in the long-term follow-up. Four patients received a re-transplantation due to CAV. Our group in Giessen follows the strategy to reduce the bridging of patients by VADs to heart transplantation, which resulted in only about 9% of the patients who received a VAD before cardiac transplantation.

Raissadati et al. report a strict protocol to obtain endomyocardial biopsies (EMB) and consequent treatment of subclinical rejection findings, which may in some cases lead to the treatment of merely a histological finding rather than a clinical rejection but may also potentially have improved their long-term outcome. Alternative methods for the detection of subclinical rejection have been implemented by the Berlin group [3]. Our strategy involves obtaining an EMB in all patients before discharge. Patients older than 10 years receive cardiac catheterization yearly to monitor CAV and an EMB is obtained if required.

Meanwhile alternative methods for definite treatment or bridging of patients with dilated left-sided cardiomyopathy but preserved right ventricular function produce astonishing results [5]. This "mechanical" reverse remodelling in conjunction with regenerative therapies may substantially reduce the need for donor organs in the paediatric population considering the high regenerative capacity of the young heart, or guaranty a safe bridging to cardiac transplantation.

Conflict of interest: none declared.

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