Heart Transplantation in Adults With Congenital Heart Disease: 100% Survival With Operations Performed by a Surgeon Specializing in Congenital Heart Disease in an Adult Hospital Makoto Mori, BS, David Vega, MD, Wendy Book, MD, and Brian E. Kogon, MD
Background. Cardiac transplantation in adult patients with congenital heart disease poses numerous challenges. The optimal operative and postoperative management strategies remain unclear. The purpose of our study was to (1) characterize the adult patient with a congenital heart condition undergoing transplantation, the operation, and the postoperative course; (2) report the survival after heart transplantation at our center; and (3) discuss issues surrounding the unique setting we provide for the operative and postoperative care of this complex patient cohort. Methods. We performed a retrospective cohort study of 12 consecutive adult patients with a prior history of congenital heart disease who underwent heart transplantation at a single, large, academic center between September 1, 2005, and September 1, 2013. The operations were performed by a surgeon specializing in congenital heart disease in an adult hospital. Postoperative care was provided jointly by that surgeon and the adult cardiac transplantation team. Results. At operation, the median age and weight were 41 years (range, 16 to 72 years) and 65 kg (range, 45 to 104 kg), and 100% of patients had undergone previous operations. The median donor ischemic time was 197 minutes
(range, 137 to 282 minutes). The median cardiopulmonary bypass time was 210 minutes (range, 175 to 457 minutes), and the median total operating time was 582 minutes (range, 389 to 968 minutes). Three patients required mechanical support to be weaned from cardiopulmonary bypass. Postoperatively, 3 patients required the addition of mechanical support in the intensive care unit, and 3 patients required tracheostomy for prolonged ventilation. The majority of patients had a complicated postoperative course (66%). The median number of noncardiac consultants required to help care for these patients was four (range, two to 12). The mortality was 0%. Conclusions. Cardiac transplantation in adults with congenital cardiac disease is challenging, is fraught with adverse events, and requires meticulous care and teamwork for success. A surgeon specializing in congenital heart conditions may be best to handle the operative challenges, and an adult hospital with access to certain technology and consultant services may be best to handle the postoperative challenges in this difficult patient population.
P
hospital. We have demonstrated that this system may offer the patients the greatest opportunity for survival [2]. The purpose of our study was to (1) characterize the adult patient with congenital heart disease undergoing transplantation, the operation, and the postoperative course; (2) report the survival after heart transplantation at our center; and (3) compare our operative and postoperative care environment with that of other centers in the nation.
atients with congenital heart disease experience inferior short-term survival after orthotopic heart transplantation compared with patients undergoing transplantation for noncongenital pathologic conditions. The data show a 1-month survival of 86%, the lowest rate among the analyzed subpopulations (congenital, cardiomyopathy, valvular, coronary artery disease, and retransplantation) [1]. These transplant operations are often technically challenging because of anatomic constraints and prior congenital heart operations. The postoperative courses can also be complicated, requiring consultations from numerous subspecialists. Our operations in adults with congenital heart disease, including heart transplantations in these adults, are performed by a surgeon specializing in congenital heart conditions within an adult
(Ann Thorac Surg 2015;99:2173–8) Ó 2015 by The Society of Thoracic Surgeons
Patients and Methods We performed a retrospective cohort study of 12 consecutive adult patients with a prior history of congenital heart disease who underwent orthotopic transplantation at a single, large, academic center between September 1, 2005, and September 1, 2013.
Accepted for publication March 3, 2015.
Patient Population
Address correspondence to Dr Kogon, Emory University, 1405 Clifton Rd, Atlanta, GA 30322; e-mail: [email protected].
The demographic data collected included age, weight, gender, and ethnicity. The preoperative data collected
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.03.001
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Department of Cardiothoracic Surgery and Cardiology, Emory University School of Medicine, Atlanta, Georgia
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included congenital diagnosis and current anatomy, medical comorbidities, and condition at the time of transplantation. The operative data collected included type of surgeon, location of operation, number of prior operations, and duration of cardiopulmonary bypass and operation. The postoperative data collected included the need for mechanical support or tracheostomy, adverse events, the need for noncardiac consultants, and survival status. All adverse events were identified, in addition to those typically reported in the Society of Thoracic Surgeons database (operative mortality, stroke, renal failure, prolonged ventilation, deep sternal infection, reoperation, length of stay >6 days, and length of stay >14 days).
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(ccTGA) (2), and D-transposition of the great arteries (DTGA) (3). The 7 patients with single-ventricle heart disease were listed for transplantation secondary to Fontan failure. The remaining 5 patients, 2 with CCTGA and 3 with D-TGA after atrial switch operations, were listed for transplantation secondary to systemic right ventricular failure. Six patients were called in from home, and 6 patients were in the hospital at the time of transplantation. The median time from admission to operation was 4 days (range, 0 to 148 days). One patient was intubated while in cardiogenic shock, and 5 patients were receiving support
Table 1. Demographics and Preoperative Characteristics
Care Environment All of the operations were performed by a surgeon specializing in congenital heart disease in an adult hospital. Postoperative care was provided jointly by that surgeon and the adult cardiac transplantation team, also within the adult hospital. Long-term follow-up was provided by the adult cardiac transplantation team in the outpatient clinic. For comparison, we queried other programs treating adults with congenital heart disease (n ¼ 11) in the United States to assess the environmental variability in which transplantations in these adults are performed. The programs queried included those whose programs for adults with congenital cardiac disease are represented in the Alliance for Adult Research in Congenital Cardiology (AARCC). The programs were University of Michigan, Ann Arbor; Brigham and Women’s Hospital/ Harvard Medical School, Boston; Nationwide Children’s Hospital/Ohio State University, Columbus; Heart Institute/Children’s Hospital of Pittsburgh of UPMC, Pittsburgh; Hershey Medical Center/Pennsylvania State University, Hershey; Medical College of Wisconsin, Milwaukee; University of Colorado, Denver; Knight Cardiovascular Institute/Oregon Health and Science University, Portland; Texas Children’s Hospital/Baylor College of Medicine, Houston; Children’s National Medical Center, Washington, DC; and University of California, Los Angeles.
Institutional Review Board Institutional review board approval was obtained to perform this retrospective study, and individual patient consent was waived. A descriptive analysis is reported throughout.
Results Characteristics of Patients At transplantation, the patients’ median age and weight were 41 years (range, 16 to 72 years) and 65 kg (range, 45 to 104 kg) (Table 1); 58% were male, 92% were white, and 8% were African-American. The original cardiac diagnoses included tricuspid atresia (3), double-inlet left ventricle (2), unbalanced atrioventricular septal defect (2), congenitally corrected transposition of the great arteries
Total Patients (n ¼ 12) Characteristic Demographics Age at operation (days) Weight at operation (kg) Gender Male Female Race White African-American Other Congenital diagnosis/current anatomy Single ventricle - s/p Fontan operation ccTGA D-TGA - s/p atrial switch operation Preoperative medical history Peripheral vascular disease Cerebrovascular disease Chronic lung disease Diabetes Hypertension Endocarditis Immunosuppressive treatment Renal failure - dialysis Hyperlipidemia Tobacco Preoperative cardiac status UNOS status IA IB NYHA class 4 Intubated Cardiogenic shock Inotropes Mechanical support
n
%
Median
Range
41 65
(20–47) (45–104)
7 5
58 42
. .
. .
11 1 0
92 8 0
. . .
. . .
7
58
.
.
2 3
17 25
. .
. .
0 5 1 0 3 0 2
0 42 8 0 25 0 17
. . . . . . .
. . . . . . .
2 2 0
17 17 0
. . .
. . .
3 9 12 1 1 5 0
25 75 100 8 8 42 0
. . . . . . .
. . . . . . .
ccTGA ¼ congenitally corrected transposition of the great arteries; D-TGA ¼ transposition of the great arteries; NYHA ¼ New York Heart Association; s/p ¼ status post; UNOS ¼ United Network for Organ Sharing.
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with intravenous inotropic agents. No patients were receiving mechanical support.
Table 3. Postoperative Characteristics
Characteristics of Operation
Characteristic
All of the patients had undergone prior open-heart surgical procedures (Table 2). Of note, 2 of 12 patients underwent additional concomitant organ transplantation during the index hospitalization: kidney transplantation for renal cell carcinoma and liver/kidney transplantation for hepatorenal dysfunction in a failing Fontan pathologic condition. The orthotopic heart transplantation was the first reoperative sternotomy in 5 patients (42%), the second in 3 patients (25%), the third in 2 patients (17%), and the fourth in 2 patients (17%). All of the patients required additional reconstructive procedures: takedown of a cavopulmonary connection with pulmonary artery reconstruction (7), innominate vein construction in a patient with interrupted inferior vena cava and hemiazygos continuation to a left superior vena cava (1), right superior vena cava reconstruction (1), reconstruction of the atrial septum (3), and contouring of the aorta (2). The median ischemic time for donors was 197 minutes (range, 137 to 282 minutes). The median cardiopulmonary bypass time was 210 minutes (range, 175 to 457 minutes), and the median total operating time was 582 minutes (range, 389 to 968 minutes). Three patients required mechanical support to be weaned from cardiopulmonary bypass. The first patient had a Fontan procedure to a single left lung. His transplantation was complicated by right heart failure resulting from elevated pulmonary vascular resistance and significant bleeding, requiring placement of an intra-aortic
Mechanical support Placed in operating room Placed in ICU Tracheostomy (performed in ICU) STS database adverse events Operative mortality Stroke Renal failure Prolonged ventilation Deep sternal infection Reoperation Length of stay >6 days Length of stay >14 days Number of noncardiac consultants Timing Total ventilation (hours) ICU length of stay (hours) Total length of stay (days) Discharged to rehabilitation facility
Total Patients (n ¼ 12) Characteristic Location of operation Pediatric hospital Adult hospital Surgeon Pediatric cardiac surgeon Adult cardiac surgeon Prior cardiac operation Reoperative sternotomy number 1 2 3 4 Donor ischemic time (min) Cardiopulmonary bypass time (min) Cross-clamp time (min) Total operative time (min) Need for mechanical support
n
%
Median
Range
0 12
0 100
. .
. .
12 0 12
100 0 100
. . .
. . .
5 3 2 2
42 25 17 17
. . . . 197 210
. . . . (137–282) (175–457)
130 582 .
(92–233) (389–968) .
3
25
Total Patients (n ¼ 12)
ICU ¼ intensive care unit;
n
%
Median
Range
3 3 3
25 25 25
. . .
. . .
0 0 1 12 0 8 12 9
0 0 8 100 0 67 100 75
. . . . . . . . 4
. . . . . . . . (2–12)
149 272 23 .
(18–1792) (114–1853) (9–108) .
5
42
STS ¼ The Society of Thoracic Surgeons.
balloon pump (IABP), a right ventricular assist device (RVAD), and an eventual left ventricular assist device (LVAD). The second patient had ccTGA. Her transplantation was complicated by similar issues, requiring placement of an IABP and an RVAD. The third patient had a Fontan procedure with liver and renal failure. The heart transplantation went exceedingly well, but the function deteriorated during the liver transplantation, requiring institution of femoral venoarterial extracorporeal membrane oxygenation (ECMO). The CentriMag (Thoratec Corporation, Pleasanton, CA) was used in all cases of VAD support.
Characteristics of Postoperative Course Additional means of mechanical support were added in the intensive care unit (ICU) in 3 unique patients: LVAD, IABP, and venovenous ECMO (Table 3). Ultimately, this resulted in a total of 5 patients (42%) requiring some means of mechanical support either in the operating room or in the ICU. Three patients (25%) required tracheostomy, which was performed percutaneously at the bedside in the ICU. For those adverse events typically reported in the Society of Thoracic Surgeons database, 100% met the criteria for prolonged ventilation, and 67% required reoperation. All patients (100%) had a prolonged length of stay (longer than 6 days), and 75% stayed longer than 14 days. No patients experienced a neurologic event. Other adverse events were also common, occurring in 8 of 12 patients (67%).
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Table 2. Operative Characteristics
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A complete list is shown in Table 4. During the inhospital recovery, patients required involvement from a median of four consulting services (range, two to 12) (Table 5). Five patients were discharged to a rehabilitation facility.
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Program Comparison In seven of 11 programs, a surgeon specializing in cardiac transplantation in adults performed the transplantation in an adult hospital (Table 6). In the other four programs, the primary transplantation surgeon was a specialist in congenital cardiac disease: three operating in a pediatric hospital and one operating in a combined pediatric and adult hospital. Two centers referred high-risk patients, overly complex patients, or both elsewhere for treatment. Our institution was the only center in which the operations were performed by a surgeon specializing in congenital cardiac disease in an adult hospital.
Comment General Owing to the advances in perioperative and postoperative management, more than 85% of patients with congenital heart disease now reach adulthood [3, 4]. Despite the advances in the care of this unique patient cohort, the population continues to experience premature mortality, with approximately one quarter of deaths resulting from heart failure [5]. Orthotopic heart transplantation
Table 4. List of Adverse Events Adult respiratory distress syndrome Bronchial collateral bleeding Candida spp. bacteremia Cardiac arrest Clostridium difficile colitis Esophageal stricture Hematuria from catheter trauma Klebsiella spp. bacteremia Massive hemorrhage from renal biopsy Need for biventricular assist device implantation Need for respiratory venovenous ECMO Neutropenia Obstructive jaundice Pseudomonas spp. tracheobronchitis/pneumonia Pulmonary hypertension Renal insufficiency Respiratory insufficiency Sacral decubitus Staphylococcus spp. bacteremia Supraventricular tachycardia Transplantation-related diabetes mellitus Upper extremity limb ischemia Urinary tract infection Vocal cord paralysis ECMO ¼ extracorporeal membrane oxygenation.
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frequently remains the only definitive treatment in such cases of end-stage heart failure. Over the past two decades, an increasing number of adult congenital patients have been listed for orthotopic heart transplantation, accounting for 2.5% of all adults listed for primary cardiac transplantation [6].
The Operation As demonstrated by this summary, transplantation in an adult patient with congenital heart disease is difficult. Reoperative surgical procedures are commonplace. Relevant anatomic considerations such as anomalous pulmonary venous return, anomalous systemic venous return, abnormal atrial connections or situs, absence of a main pulmonary artery or unusual pulmonary artery connections, and abnormal aortic anatomy and position frequently require additional reconstructive procedures. Cardiopulmonary bypass times are often prolonged, and mechanical support is often required to wean patients from cardiopulmonary bypass. The limited number of patients and reports make comparison with other programs difficult. Additionally, many studies include children and adults or include adults with diagnoses of noncongenital conditions. Nonetheless, original diagnoses of congenital conditions and indications for operation in our cohort seem similar to those in other reports [7]. By contrast, our reoperative sternotomy rates seem to be slightly higher than others have reported, whereas our ischemic times and hospital mortality seem to be lower. Other studies have reported reoperations in 39 of 45 patients (87%), with a mean of three previous operations, and in 453 of 488 patients (93%) [8, 9]. Mean ischemic times of 228 minutes for patients having one to two previous sternotomies and 242 minutes for patients having more than three sternotomies have been reported [8]. In a study limited to Glenn and Fontan patients undergoing transplantation, the mean cardiopulmonary bypass times, cross-clamp times, and donor ischemic times were 288, 180, and 282 minutes, respectively [10]. In a series of small single-institution experiences with transplantation in adults with congenital heart disease, hospital mortalities were reported at 0% (n ¼ 4), 0% (n ¼ 14), 7% (n ¼ 14), 38% (n ¼ 24), 43% (n ¼ 9), and 50% (n ¼ 8) [11]. The increased anatomic complexity encountered during transplantation in adults with congenital heart disease is associated with a greater need for reconstructive procedures at the time of transplantation, increased ischemic times, and increased risk of bleeding [12]. It has been postulated that this accounts for the increased perioperative mortality seen in this group of patients [12]. In various studies, the risk factors for adverse outcomes in transplantation in these patients have included Fontan anatomy, the need for pulmonary artery reconstruction, long ischemic times, and technical and surgical adverse events occurring during transplantation [8, 12, 13].
The Recovery Concomitant medical problems and multisystem organ fxailure make the postoperative care tedious and
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Optimal Setting In looking specifically at transplantation in adults, shortterm survival is inferior in the population with congenital disease compared with those with noncongenital conditions [1, 6, 13]. The data show a 1-month survival of 86%% in adult patients with congenital conditions, the lowest among the analyzed subpopulations (congenital diagnosis, cardiomyopathy, valvular, coronary artery disease, and retransplantation) [1]. However, it is critical for these patients to survive the operation and initial recovery because their long-term conditional survival is the highest among the same analyzed subpopulations [1]. Specifically, a surgeon specializing in congenital heart conditions may be best to handle the operative challenges, and an adult hospital with access to certain technology and consultant services may be best to handle Table 5. Noncardiac Consultants Service Physical therapy Occupational therapy Infectious disease Speech pathology Rehabilitation medicine Nephrology Nutrition Otolaryngology Transplant surgery (liver/kidney) Endocrinology Gastroenterology Hepatology Ophthalmology Plastic surgery Pulmonology Thoracic surgery Urology Wound service
No. of Patients 11 10 6 6 5 3 3 2 2 1 1 1 1 1 1 1 1 1
Table 6. Clinical Setting for Transplantation in Adults With Congenital Conditions Program
Primary Transplantation Surgeon
Transplantation Location
1a 2 3 4 5 6a 7 8 9 10 11
Adult Congenital Congenital Adult Adult Adult Adult Adult Congenital Congenital Adult
Adult Combined Pediatric Adult Adult Adult Adult Adult Pediatric Pediatric Adult
a
High-risk or complex cases referred out.
the postoperative challenges in this difficult patient population. We have previously demonstrated that the outcomes of operations in adults with congenital cardiac disease are optimal when the operations are performed by a surgeon specializing in congenital heart disease within an adult hospital [2, 15]. Others have also shown improved outcomes when the operation is performed by such a surgeon, as opposed to a surgeon specalizing in adult cardiac conditions [16]. The current practice pattern in this regard varies widely, as shown by Table 6. Since 2000, our operations in adults with congenital conditions, including transplantations, have been performed by a specialist in congenital heart disease. Postoperative care is a joint effort, led both by that surgeon and by adult cardiac transplantation teams. With this system, we have achieved 100% survival in 12 consecutive transplantations in adults with congenital conditions between September 1, 2005, and September 1, 2013.
Limitations This study is limited by its observational nature and the inherent limitations of a retrospective database study. It is also limited to the small number of patients specifically undergoing cardiac transplantation. However, as already described, we have shown similar favorable outcomes in a large number of adult patients undergoing operations for congenital heart disease, not isolated to transplantation [2].
Conclusions Cardiac transplantation in adults with congenital cardiac disease is challenging, is fraught with adverse events, and requires meticulous care and teamwork for success. A surgeon specializing in congenital heart disease may be best to handle the operative challenges, and an adult hospital with access to certain technology and consultant services may be best to handle the postoperative challenges in this difficult patient population. We have achieved 100% survival with this configuration, and it may
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cumbersome. There is often significant pulmonary, hepatic, intestinal, and renal insufficiency, particularly in patients with failing Fontan pathologic conditions [14]. Such challenges are demonstrated by this case series. Ultimately, 5 patients required mechanical cardiac support. Different means of support may be available, depending on the care environment. The Centrimag, which we used in all cases of VAD support, and the Impella (Abiomed, Inc. Danvers, MA), another useful means of short-term support, are only available at our adult hospital. Additionally, in the 3 patients requiring tracheostomy tube placement, the procedure was performed percutaneously at the bedside by the adult critical care team—again, a service only available at our adult hospital. Postoperative adverse events were common, and a median of four noncardiac consultant teams (range, two to 12 teams) were involved in the postoperative care of each patient.
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represent the optimal clinical setting for the operative and postoperative care of these complex patients.
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References 1. Lund LH, Edwards LB, Kucheryavaya AY, et al. The Registry of the International Society for Heart and Lung Transplantation: Thirtieth Official Adult Heart Transplant Report– 2013; focus theme: age. J Heart Lung Transplant 2013;32: 951–64. 2. Kogon BE, Plattner C, Leong T, et al. Adult congenital heart surgery: adult or pediatric facility? Adult or pediatric surgeon? Ann Thorac Surg 2009;87:833–40. 3. van der Bom T, Bouma BJ, Meijboom FJ, Zwinderman AH, Mulder BJ. The prevalence of adult congenital heart disease, results from a systematic review and evidence based calculation. Am Heart J 2012;164:568–75. 4. Marelli AJ, Mackie AS, Ionescu-Ittu R, Rahme E, Pilote L. Congenital heart disease in the general population: changing prevalence and age distribution. Circulation 2007;115:163–72. 5. Verheugt CL, Uiterwaal C, van der Velde ET, et al. Mortality in adult congenital heart disease. Eur Heart J 2010;31:1220–9. 6. Davies RR, Russo MJ, Yang J, Quaegebeur JM, Mosca RS, Chen JM. Listing and transplanting adults with congenital heart disease. Circulation 2011;123:759–67. 7. Stewart G, Mayer J. Heart transplantation in adults with congenital heart disease. Heart Fail Clin 2014;10:207–18.
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8. Lamour JM, Kanter KR, Naftel DC, et al. The effect of age, diagnosis, and previous surgery in children and adults undergoing heart transplantation for congenital heart disease. J Am Coll Cardiol 2009;54:160–5. 9. Robinson J, Driscoll D, O’Leary P, Burkhart HM, Dearani JA. Cardiac and multiorgan transplantation for end-stage congenital heart disease. Mayo Clin Proc 2014;89:478–83. 10. Jayakumar KA, Addonizio LJ, Kichuk-Chrisant MR, et al. Cardiac transplantation after the Fontan or Glenn procedure. J Am Coll Cardiol 2004;44:2065–72. 11. Hosseinpour AR, Cullen S, Tsang VT. Transplantation for adults with congenital heart disease. Eur J Cardiothorac Surg 2006;30:508–14. 12. Burchill LJ, Edwards LB, Dipchand AI, Stehlik J, Ross HJ. Impact of adult congenital heart disease on survival and mortality after heart transplantation. J Heart Lung Transplant 2014;33:1157–63. 13. Chen JM, Davies RR, Mital SR, et al. Trends and outcomes in transplantation for complex congenital heart disease: 1984 to 2004. Ann Thorac Surg 2004;78:1352–61. 14. de Leval MR, Deanfield JE. Four decades of Fontan palliation. Nat Rev Cardiol 2010;7:520–7. 15. Kogon B, Grudziak J, Sahu A, et al. Surgery in adults with congenital heart disease: risk factors for morbidity and mortality. Ann Thorac Surg 2013;95:1377–82. 16. Karamlou T, Diggs BS, Person T, Ungerleider RM, Welke KF. National practice patterns for management of adult congenital heart disease: operation by pediatric heart surgeons decreases in-hospital death. Circulation 2008;118:2345–52.
INVITED COMMENTARY The manuscript written by Mori and colleagues [1] focuses on their reported 100% survival in 12 orthotopic cardiac transplant patients, ranging in age from 16 to 72 years, and performed over an 8-year period between 2005 and 2013. This is a very impressive statistic, matched in the US by only a few other centers. The paper provides useful information on their methods and what they feel might be contributing to such a laudable statistic. The data allow other centers to potentially identify differences that could be further explored to improve outcomes in this higher risk subpopulation of adult congenital heart disease transplant cases. Less comorbidities do not seem to account for the difference in this cohort as they had similar statistics to those in the other centers. The main message of this paper is that the combination of a pediatric congenital heart surgeon in an adult hospital environment is responsible for the outstanding results observed. However, for this to be confirmed it would be helpful to look deeper into the series of “small” singleinstitution experiences referenced in their paper that had from 4 to 24 patients, similar numbers to their own. Within those reports there were a few centers that also reported 0% mortality, yet the authors did not compare these with their own report and thus the beneficial combined role of the pediatric surgeon and adult hospital is circumstantial at best. It is not so farfetched to suggest that the skills of the surgeon impact on outcome and so a pediatric heart surgeon would perhaps have more experience in this unique subset of transplant patients, thus favoring a most positive outcome. Examining the surgical statistics such as aortic cross-clamp or cardiopulmonary bypass times might support this. However Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
when compared with other centers, these yielded no significant differences. One difference was their much shorter donor organ ischemic time, by as much as 1.5 hours. The possibility that the organ itself might have suffered less ischemic injury, even pre-transplant, should also be considered as a potential contributing factor to their zero mortality. The final aspect to explore is whether their postoperative support strategies differed from other centers. Was a more aggressive use of mechanical circulatory support, which for their cohort was up to 50%, another contributor to their zero mortality? Though comparative data for this were not provided, this issue was indirectly referred to in their conclusion when discussing adult centers with “access to certain technologies” and worth further consideration. This interesting and thought provoking article is inspiring and the authors are to be commended for their successful efforts. Carin Wittnich, DVM/MS (Exper Surg) Department of Surgery University of Toronto Medical Sciences Bldg, Rm 7256 1 King’s College Circle Toronto, Ontario, Canada M5S 1A8 e-mail: [email protected]
Reference 1. Mori M, Vega D, Book W, Kogon BE. Heart transplantation in adults with congenital heart disease: 100% survival with operations performed by a surgeon specializing in congenital heart disease in an adult hospital. Ann Thorac Surg 2015;99:2173–8.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.04.043
Background. Cardiac transplantation in adult patients with congenital heart disease poses numerous challenges. The optimal operative and postoperative management strategies remain unclear. The purpose of our study was to (1) characterize the adult patient with a congenital heart condition undergoing transplantation, the operation, and the postoperative course; (2) report the survival after heart transplantation at our center; and (3) discuss issues surrounding the unique setting we provide for the operative and postoperative care of this complex patient cohort. Methods. We performed a retrospective cohort study of 12 consecutive adult patients with a prior history of congenital heart disease who underwent heart transplantation at a single, large, academic center between September 1, 2005, and September 1, 2013. The operations were performed by a surgeon specializing in congenital heart disease in an adult hospital. Postoperative care was provided jointly by that surgeon and the adult cardiac transplantation team. Results. At operation, the median age and weight were 41 years (range, 16 to 72 years) and 65 kg (range, 45 to 104 kg), and 100% of patients had undergone previous operations. The median donor ischemic time was 197 minutes
(range, 137 to 282 minutes). The median cardiopulmonary bypass time was 210 minutes (range, 175 to 457 minutes), and the median total operating time was 582 minutes (range, 389 to 968 minutes). Three patients required mechanical support to be weaned from cardiopulmonary bypass. Postoperatively, 3 patients required the addition of mechanical support in the intensive care unit, and 3 patients required tracheostomy for prolonged ventilation. The majority of patients had a complicated postoperative course (66%). The median number of noncardiac consultants required to help care for these patients was four (range, two to 12). The mortality was 0%. Conclusions. Cardiac transplantation in adults with congenital cardiac disease is challenging, is fraught with adverse events, and requires meticulous care and teamwork for success. A surgeon specializing in congenital heart conditions may be best to handle the operative challenges, and an adult hospital with access to certain technology and consultant services may be best to handle the postoperative challenges in this difficult patient population.
P
hospital. We have demonstrated that this system may offer the patients the greatest opportunity for survival [2]. The purpose of our study was to (1) characterize the adult patient with congenital heart disease undergoing transplantation, the operation, and the postoperative course; (2) report the survival after heart transplantation at our center; and (3) compare our operative and postoperative care environment with that of other centers in the nation.
atients with congenital heart disease experience inferior short-term survival after orthotopic heart transplantation compared with patients undergoing transplantation for noncongenital pathologic conditions. The data show a 1-month survival of 86%, the lowest rate among the analyzed subpopulations (congenital, cardiomyopathy, valvular, coronary artery disease, and retransplantation) [1]. These transplant operations are often technically challenging because of anatomic constraints and prior congenital heart operations. The postoperative courses can also be complicated, requiring consultations from numerous subspecialists. Our operations in adults with congenital heart disease, including heart transplantations in these adults, are performed by a surgeon specializing in congenital heart conditions within an adult
(Ann Thorac Surg 2015;99:2173–8) Ó 2015 by The Society of Thoracic Surgeons
Patients and Methods We performed a retrospective cohort study of 12 consecutive adult patients with a prior history of congenital heart disease who underwent orthotopic transplantation at a single, large, academic center between September 1, 2005, and September 1, 2013.
Accepted for publication March 3, 2015.
Patient Population
Address correspondence to Dr Kogon, Emory University, 1405 Clifton Rd, Atlanta, GA 30322; e-mail: [email protected].
The demographic data collected included age, weight, gender, and ethnicity. The preoperative data collected
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.03.001
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Department of Cardiothoracic Surgery and Cardiology, Emory University School of Medicine, Atlanta, Georgia
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included congenital diagnosis and current anatomy, medical comorbidities, and condition at the time of transplantation. The operative data collected included type of surgeon, location of operation, number of prior operations, and duration of cardiopulmonary bypass and operation. The postoperative data collected included the need for mechanical support or tracheostomy, adverse events, the need for noncardiac consultants, and survival status. All adverse events were identified, in addition to those typically reported in the Society of Thoracic Surgeons database (operative mortality, stroke, renal failure, prolonged ventilation, deep sternal infection, reoperation, length of stay >6 days, and length of stay >14 days).
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(ccTGA) (2), and D-transposition of the great arteries (DTGA) (3). The 7 patients with single-ventricle heart disease were listed for transplantation secondary to Fontan failure. The remaining 5 patients, 2 with CCTGA and 3 with D-TGA after atrial switch operations, were listed for transplantation secondary to systemic right ventricular failure. Six patients were called in from home, and 6 patients were in the hospital at the time of transplantation. The median time from admission to operation was 4 days (range, 0 to 148 days). One patient was intubated while in cardiogenic shock, and 5 patients were receiving support
Table 1. Demographics and Preoperative Characteristics
Care Environment All of the operations were performed by a surgeon specializing in congenital heart disease in an adult hospital. Postoperative care was provided jointly by that surgeon and the adult cardiac transplantation team, also within the adult hospital. Long-term follow-up was provided by the adult cardiac transplantation team in the outpatient clinic. For comparison, we queried other programs treating adults with congenital heart disease (n ¼ 11) in the United States to assess the environmental variability in which transplantations in these adults are performed. The programs queried included those whose programs for adults with congenital cardiac disease are represented in the Alliance for Adult Research in Congenital Cardiology (AARCC). The programs were University of Michigan, Ann Arbor; Brigham and Women’s Hospital/ Harvard Medical School, Boston; Nationwide Children’s Hospital/Ohio State University, Columbus; Heart Institute/Children’s Hospital of Pittsburgh of UPMC, Pittsburgh; Hershey Medical Center/Pennsylvania State University, Hershey; Medical College of Wisconsin, Milwaukee; University of Colorado, Denver; Knight Cardiovascular Institute/Oregon Health and Science University, Portland; Texas Children’s Hospital/Baylor College of Medicine, Houston; Children’s National Medical Center, Washington, DC; and University of California, Los Angeles.
Institutional Review Board Institutional review board approval was obtained to perform this retrospective study, and individual patient consent was waived. A descriptive analysis is reported throughout.
Results Characteristics of Patients At transplantation, the patients’ median age and weight were 41 years (range, 16 to 72 years) and 65 kg (range, 45 to 104 kg) (Table 1); 58% were male, 92% were white, and 8% were African-American. The original cardiac diagnoses included tricuspid atresia (3), double-inlet left ventricle (2), unbalanced atrioventricular septal defect (2), congenitally corrected transposition of the great arteries
Total Patients (n ¼ 12) Characteristic Demographics Age at operation (days) Weight at operation (kg) Gender Male Female Race White African-American Other Congenital diagnosis/current anatomy Single ventricle - s/p Fontan operation ccTGA D-TGA - s/p atrial switch operation Preoperative medical history Peripheral vascular disease Cerebrovascular disease Chronic lung disease Diabetes Hypertension Endocarditis Immunosuppressive treatment Renal failure - dialysis Hyperlipidemia Tobacco Preoperative cardiac status UNOS status IA IB NYHA class 4 Intubated Cardiogenic shock Inotropes Mechanical support
n
%
Median
Range
41 65
(20–47) (45–104)
7 5
58 42
. .
. .
11 1 0
92 8 0
. . .
. . .
7
58
.
.
2 3
17 25
. .
. .
0 5 1 0 3 0 2
0 42 8 0 25 0 17
. . . . . . .
. . . . . . .
2 2 0
17 17 0
. . .
. . .
3 9 12 1 1 5 0
25 75 100 8 8 42 0
. . . . . . .
. . . . . . .
ccTGA ¼ congenitally corrected transposition of the great arteries; D-TGA ¼ transposition of the great arteries; NYHA ¼ New York Heart Association; s/p ¼ status post; UNOS ¼ United Network for Organ Sharing.
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with intravenous inotropic agents. No patients were receiving mechanical support.
Table 3. Postoperative Characteristics
Characteristics of Operation
Characteristic
All of the patients had undergone prior open-heart surgical procedures (Table 2). Of note, 2 of 12 patients underwent additional concomitant organ transplantation during the index hospitalization: kidney transplantation for renal cell carcinoma and liver/kidney transplantation for hepatorenal dysfunction in a failing Fontan pathologic condition. The orthotopic heart transplantation was the first reoperative sternotomy in 5 patients (42%), the second in 3 patients (25%), the third in 2 patients (17%), and the fourth in 2 patients (17%). All of the patients required additional reconstructive procedures: takedown of a cavopulmonary connection with pulmonary artery reconstruction (7), innominate vein construction in a patient with interrupted inferior vena cava and hemiazygos continuation to a left superior vena cava (1), right superior vena cava reconstruction (1), reconstruction of the atrial septum (3), and contouring of the aorta (2). The median ischemic time for donors was 197 minutes (range, 137 to 282 minutes). The median cardiopulmonary bypass time was 210 minutes (range, 175 to 457 minutes), and the median total operating time was 582 minutes (range, 389 to 968 minutes). Three patients required mechanical support to be weaned from cardiopulmonary bypass. The first patient had a Fontan procedure to a single left lung. His transplantation was complicated by right heart failure resulting from elevated pulmonary vascular resistance and significant bleeding, requiring placement of an intra-aortic
Mechanical support Placed in operating room Placed in ICU Tracheostomy (performed in ICU) STS database adverse events Operative mortality Stroke Renal failure Prolonged ventilation Deep sternal infection Reoperation Length of stay >6 days Length of stay >14 days Number of noncardiac consultants Timing Total ventilation (hours) ICU length of stay (hours) Total length of stay (days) Discharged to rehabilitation facility
Total Patients (n ¼ 12) Characteristic Location of operation Pediatric hospital Adult hospital Surgeon Pediatric cardiac surgeon Adult cardiac surgeon Prior cardiac operation Reoperative sternotomy number 1 2 3 4 Donor ischemic time (min) Cardiopulmonary bypass time (min) Cross-clamp time (min) Total operative time (min) Need for mechanical support
n
%
Median
Range
0 12
0 100
. .
. .
12 0 12
100 0 100
. . .
. . .
5 3 2 2
42 25 17 17
. . . . 197 210
. . . . (137–282) (175–457)
130 582 .
(92–233) (389–968) .
3
25
Total Patients (n ¼ 12)
ICU ¼ intensive care unit;
n
%
Median
Range
3 3 3
25 25 25
. . .
. . .
0 0 1 12 0 8 12 9
0 0 8 100 0 67 100 75
. . . . . . . . 4
. . . . . . . . (2–12)
149 272 23 .
(18–1792) (114–1853) (9–108) .
5
42
STS ¼ The Society of Thoracic Surgeons.
balloon pump (IABP), a right ventricular assist device (RVAD), and an eventual left ventricular assist device (LVAD). The second patient had ccTGA. Her transplantation was complicated by similar issues, requiring placement of an IABP and an RVAD. The third patient had a Fontan procedure with liver and renal failure. The heart transplantation went exceedingly well, but the function deteriorated during the liver transplantation, requiring institution of femoral venoarterial extracorporeal membrane oxygenation (ECMO). The CentriMag (Thoratec Corporation, Pleasanton, CA) was used in all cases of VAD support.
Characteristics of Postoperative Course Additional means of mechanical support were added in the intensive care unit (ICU) in 3 unique patients: LVAD, IABP, and venovenous ECMO (Table 3). Ultimately, this resulted in a total of 5 patients (42%) requiring some means of mechanical support either in the operating room or in the ICU. Three patients (25%) required tracheostomy, which was performed percutaneously at the bedside in the ICU. For those adverse events typically reported in the Society of Thoracic Surgeons database, 100% met the criteria for prolonged ventilation, and 67% required reoperation. All patients (100%) had a prolonged length of stay (longer than 6 days), and 75% stayed longer than 14 days. No patients experienced a neurologic event. Other adverse events were also common, occurring in 8 of 12 patients (67%).
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Table 2. Operative Characteristics
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A complete list is shown in Table 4. During the inhospital recovery, patients required involvement from a median of four consulting services (range, two to 12) (Table 5). Five patients were discharged to a rehabilitation facility.
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Program Comparison In seven of 11 programs, a surgeon specializing in cardiac transplantation in adults performed the transplantation in an adult hospital (Table 6). In the other four programs, the primary transplantation surgeon was a specialist in congenital cardiac disease: three operating in a pediatric hospital and one operating in a combined pediatric and adult hospital. Two centers referred high-risk patients, overly complex patients, or both elsewhere for treatment. Our institution was the only center in which the operations were performed by a surgeon specializing in congenital cardiac disease in an adult hospital.
Comment General Owing to the advances in perioperative and postoperative management, more than 85% of patients with congenital heart disease now reach adulthood [3, 4]. Despite the advances in the care of this unique patient cohort, the population continues to experience premature mortality, with approximately one quarter of deaths resulting from heart failure [5]. Orthotopic heart transplantation
Table 4. List of Adverse Events Adult respiratory distress syndrome Bronchial collateral bleeding Candida spp. bacteremia Cardiac arrest Clostridium difficile colitis Esophageal stricture Hematuria from catheter trauma Klebsiella spp. bacteremia Massive hemorrhage from renal biopsy Need for biventricular assist device implantation Need for respiratory venovenous ECMO Neutropenia Obstructive jaundice Pseudomonas spp. tracheobronchitis/pneumonia Pulmonary hypertension Renal insufficiency Respiratory insufficiency Sacral decubitus Staphylococcus spp. bacteremia Supraventricular tachycardia Transplantation-related diabetes mellitus Upper extremity limb ischemia Urinary tract infection Vocal cord paralysis ECMO ¼ extracorporeal membrane oxygenation.
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frequently remains the only definitive treatment in such cases of end-stage heart failure. Over the past two decades, an increasing number of adult congenital patients have been listed for orthotopic heart transplantation, accounting for 2.5% of all adults listed for primary cardiac transplantation [6].
The Operation As demonstrated by this summary, transplantation in an adult patient with congenital heart disease is difficult. Reoperative surgical procedures are commonplace. Relevant anatomic considerations such as anomalous pulmonary venous return, anomalous systemic venous return, abnormal atrial connections or situs, absence of a main pulmonary artery or unusual pulmonary artery connections, and abnormal aortic anatomy and position frequently require additional reconstructive procedures. Cardiopulmonary bypass times are often prolonged, and mechanical support is often required to wean patients from cardiopulmonary bypass. The limited number of patients and reports make comparison with other programs difficult. Additionally, many studies include children and adults or include adults with diagnoses of noncongenital conditions. Nonetheless, original diagnoses of congenital conditions and indications for operation in our cohort seem similar to those in other reports [7]. By contrast, our reoperative sternotomy rates seem to be slightly higher than others have reported, whereas our ischemic times and hospital mortality seem to be lower. Other studies have reported reoperations in 39 of 45 patients (87%), with a mean of three previous operations, and in 453 of 488 patients (93%) [8, 9]. Mean ischemic times of 228 minutes for patients having one to two previous sternotomies and 242 minutes for patients having more than three sternotomies have been reported [8]. In a study limited to Glenn and Fontan patients undergoing transplantation, the mean cardiopulmonary bypass times, cross-clamp times, and donor ischemic times were 288, 180, and 282 minutes, respectively [10]. In a series of small single-institution experiences with transplantation in adults with congenital heart disease, hospital mortalities were reported at 0% (n ¼ 4), 0% (n ¼ 14), 7% (n ¼ 14), 38% (n ¼ 24), 43% (n ¼ 9), and 50% (n ¼ 8) [11]. The increased anatomic complexity encountered during transplantation in adults with congenital heart disease is associated with a greater need for reconstructive procedures at the time of transplantation, increased ischemic times, and increased risk of bleeding [12]. It has been postulated that this accounts for the increased perioperative mortality seen in this group of patients [12]. In various studies, the risk factors for adverse outcomes in transplantation in these patients have included Fontan anatomy, the need for pulmonary artery reconstruction, long ischemic times, and technical and surgical adverse events occurring during transplantation [8, 12, 13].
The Recovery Concomitant medical problems and multisystem organ fxailure make the postoperative care tedious and
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Optimal Setting In looking specifically at transplantation in adults, shortterm survival is inferior in the population with congenital disease compared with those with noncongenital conditions [1, 6, 13]. The data show a 1-month survival of 86%% in adult patients with congenital conditions, the lowest among the analyzed subpopulations (congenital diagnosis, cardiomyopathy, valvular, coronary artery disease, and retransplantation) [1]. However, it is critical for these patients to survive the operation and initial recovery because their long-term conditional survival is the highest among the same analyzed subpopulations [1]. Specifically, a surgeon specializing in congenital heart conditions may be best to handle the operative challenges, and an adult hospital with access to certain technology and consultant services may be best to handle Table 5. Noncardiac Consultants Service Physical therapy Occupational therapy Infectious disease Speech pathology Rehabilitation medicine Nephrology Nutrition Otolaryngology Transplant surgery (liver/kidney) Endocrinology Gastroenterology Hepatology Ophthalmology Plastic surgery Pulmonology Thoracic surgery Urology Wound service
No. of Patients 11 10 6 6 5 3 3 2 2 1 1 1 1 1 1 1 1 1
Table 6. Clinical Setting for Transplantation in Adults With Congenital Conditions Program
Primary Transplantation Surgeon
Transplantation Location
1a 2 3 4 5 6a 7 8 9 10 11
Adult Congenital Congenital Adult Adult Adult Adult Adult Congenital Congenital Adult
Adult Combined Pediatric Adult Adult Adult Adult Adult Pediatric Pediatric Adult
a
High-risk or complex cases referred out.
the postoperative challenges in this difficult patient population. We have previously demonstrated that the outcomes of operations in adults with congenital cardiac disease are optimal when the operations are performed by a surgeon specializing in congenital heart disease within an adult hospital [2, 15]. Others have also shown improved outcomes when the operation is performed by such a surgeon, as opposed to a surgeon specalizing in adult cardiac conditions [16]. The current practice pattern in this regard varies widely, as shown by Table 6. Since 2000, our operations in adults with congenital conditions, including transplantations, have been performed by a specialist in congenital heart disease. Postoperative care is a joint effort, led both by that surgeon and by adult cardiac transplantation teams. With this system, we have achieved 100% survival in 12 consecutive transplantations in adults with congenital conditions between September 1, 2005, and September 1, 2013.
Limitations This study is limited by its observational nature and the inherent limitations of a retrospective database study. It is also limited to the small number of patients specifically undergoing cardiac transplantation. However, as already described, we have shown similar favorable outcomes in a large number of adult patients undergoing operations for congenital heart disease, not isolated to transplantation [2].
Conclusions Cardiac transplantation in adults with congenital cardiac disease is challenging, is fraught with adverse events, and requires meticulous care and teamwork for success. A surgeon specializing in congenital heart disease may be best to handle the operative challenges, and an adult hospital with access to certain technology and consultant services may be best to handle the postoperative challenges in this difficult patient population. We have achieved 100% survival with this configuration, and it may
CONGENITAL HEART
cumbersome. There is often significant pulmonary, hepatic, intestinal, and renal insufficiency, particularly in patients with failing Fontan pathologic conditions [14]. Such challenges are demonstrated by this case series. Ultimately, 5 patients required mechanical cardiac support. Different means of support may be available, depending on the care environment. The Centrimag, which we used in all cases of VAD support, and the Impella (Abiomed, Inc. Danvers, MA), another useful means of short-term support, are only available at our adult hospital. Additionally, in the 3 patients requiring tracheostomy tube placement, the procedure was performed percutaneously at the bedside by the adult critical care team—again, a service only available at our adult hospital. Postoperative adverse events were common, and a median of four noncardiac consultant teams (range, two to 12 teams) were involved in the postoperative care of each patient.
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represent the optimal clinical setting for the operative and postoperative care of these complex patients.
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References 1. Lund LH, Edwards LB, Kucheryavaya AY, et al. The Registry of the International Society for Heart and Lung Transplantation: Thirtieth Official Adult Heart Transplant Report– 2013; focus theme: age. J Heart Lung Transplant 2013;32: 951–64. 2. Kogon BE, Plattner C, Leong T, et al. Adult congenital heart surgery: adult or pediatric facility? Adult or pediatric surgeon? Ann Thorac Surg 2009;87:833–40. 3. van der Bom T, Bouma BJ, Meijboom FJ, Zwinderman AH, Mulder BJ. The prevalence of adult congenital heart disease, results from a systematic review and evidence based calculation. Am Heart J 2012;164:568–75. 4. Marelli AJ, Mackie AS, Ionescu-Ittu R, Rahme E, Pilote L. Congenital heart disease in the general population: changing prevalence and age distribution. Circulation 2007;115:163–72. 5. Verheugt CL, Uiterwaal C, van der Velde ET, et al. Mortality in adult congenital heart disease. Eur Heart J 2010;31:1220–9. 6. Davies RR, Russo MJ, Yang J, Quaegebeur JM, Mosca RS, Chen JM. Listing and transplanting adults with congenital heart disease. Circulation 2011;123:759–67. 7. Stewart G, Mayer J. Heart transplantation in adults with congenital heart disease. Heart Fail Clin 2014;10:207–18.
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8. Lamour JM, Kanter KR, Naftel DC, et al. The effect of age, diagnosis, and previous surgery in children and adults undergoing heart transplantation for congenital heart disease. J Am Coll Cardiol 2009;54:160–5. 9. Robinson J, Driscoll D, O’Leary P, Burkhart HM, Dearani JA. Cardiac and multiorgan transplantation for end-stage congenital heart disease. Mayo Clin Proc 2014;89:478–83. 10. Jayakumar KA, Addonizio LJ, Kichuk-Chrisant MR, et al. Cardiac transplantation after the Fontan or Glenn procedure. J Am Coll Cardiol 2004;44:2065–72. 11. Hosseinpour AR, Cullen S, Tsang VT. Transplantation for adults with congenital heart disease. Eur J Cardiothorac Surg 2006;30:508–14. 12. Burchill LJ, Edwards LB, Dipchand AI, Stehlik J, Ross HJ. Impact of adult congenital heart disease on survival and mortality after heart transplantation. J Heart Lung Transplant 2014;33:1157–63. 13. Chen JM, Davies RR, Mital SR, et al. Trends and outcomes in transplantation for complex congenital heart disease: 1984 to 2004. Ann Thorac Surg 2004;78:1352–61. 14. de Leval MR, Deanfield JE. Four decades of Fontan palliation. Nat Rev Cardiol 2010;7:520–7. 15. Kogon B, Grudziak J, Sahu A, et al. Surgery in adults with congenital heart disease: risk factors for morbidity and mortality. Ann Thorac Surg 2013;95:1377–82. 16. Karamlou T, Diggs BS, Person T, Ungerleider RM, Welke KF. National practice patterns for management of adult congenital heart disease: operation by pediatric heart surgeons decreases in-hospital death. Circulation 2008;118:2345–52.
INVITED COMMENTARY The manuscript written by Mori and colleagues [1] focuses on their reported 100% survival in 12 orthotopic cardiac transplant patients, ranging in age from 16 to 72 years, and performed over an 8-year period between 2005 and 2013. This is a very impressive statistic, matched in the US by only a few other centers. The paper provides useful information on their methods and what they feel might be contributing to such a laudable statistic. The data allow other centers to potentially identify differences that could be further explored to improve outcomes in this higher risk subpopulation of adult congenital heart disease transplant cases. Less comorbidities do not seem to account for the difference in this cohort as they had similar statistics to those in the other centers. The main message of this paper is that the combination of a pediatric congenital heart surgeon in an adult hospital environment is responsible for the outstanding results observed. However, for this to be confirmed it would be helpful to look deeper into the series of “small” singleinstitution experiences referenced in their paper that had from 4 to 24 patients, similar numbers to their own. Within those reports there were a few centers that also reported 0% mortality, yet the authors did not compare these with their own report and thus the beneficial combined role of the pediatric surgeon and adult hospital is circumstantial at best. It is not so farfetched to suggest that the skills of the surgeon impact on outcome and so a pediatric heart surgeon would perhaps have more experience in this unique subset of transplant patients, thus favoring a most positive outcome. Examining the surgical statistics such as aortic cross-clamp or cardiopulmonary bypass times might support this. However Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
when compared with other centers, these yielded no significant differences. One difference was their much shorter donor organ ischemic time, by as much as 1.5 hours. The possibility that the organ itself might have suffered less ischemic injury, even pre-transplant, should also be considered as a potential contributing factor to their zero mortality. The final aspect to explore is whether their postoperative support strategies differed from other centers. Was a more aggressive use of mechanical circulatory support, which for their cohort was up to 50%, another contributor to their zero mortality? Though comparative data for this were not provided, this issue was indirectly referred to in their conclusion when discussing adult centers with “access to certain technologies” and worth further consideration. This interesting and thought provoking article is inspiring and the authors are to be commended for their successful efforts. Carin Wittnich, DVM/MS (Exper Surg) Department of Surgery University of Toronto Medical Sciences Bldg, Rm 7256 1 King’s College Circle Toronto, Ontario, Canada M5S 1A8 e-mail: [email protected]
Reference 1. Mori M, Vega D, Book W, Kogon BE. Heart transplantation in adults with congenital heart disease: 100% survival with operations performed by a surgeon specializing in congenital heart disease in an adult hospital. Ann Thorac Surg 2015;99:2173–8.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.04.043
