ABO-incompatible heart transplantation in early childhood: An international multicenter study of clinical experiences and limits

Simon Urschel*, Ingrid M. Larsen, Richard Kirk, Julie Flett, Michael Burch, Nadine Shaw, Julia Birnbaum, Heinrich Netz, Elfriede Pahl, Kathleen L. Matthews, Richard Chinnock, Joyce K. Johnston, Kim Derkatz, Lori J. West

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

70 Scopus citations


Background: Intentional blood group (BG)-incompatible (ABOi) heart transplantation in childhood is emerging in many centers. Safety limits remain undetermined. In this multicenter study we have compiled experience on clinical and immunologic boundaries. Methods: Data from six centers in Europe and North America on ABOi transplantation were collected in a standardized survey. Results: Fifty-eight ABOi transplants were performed in 57 patients. Median age at transplant was 6.8 months (0.03 to 90 months); post-transplant follow-up was 37.7 months (0.46 to 117 months), accumulating 188 patient-years. Forty-seven percent of the patients received pretransplant mechanical circulatory support. Donors were either blood group A (n = 25), B (n = 18) or AB (n = 15). The median peak antibody titer to the donor BG pretransplant was 1:8 (0 to 1:64) for anti-A and 1:4 (0 to 1:32) for anti-B. Titers against the donor BG were lower post- than pretransplant in B recipients (p = 0.02), whereas third-party antibodies in BG O recipients developed normally post-transplant. Induction immunosuppression included anti-thymocyte globulin (61%), basiliximab (32%) or none (7%). All patients received calcineurin inhibitors, including 62% with mycophenolate mofetil, 10% with azathioprine, 2% with everolimus and 24% with steroids. There were 4 episodes of cellular rejection (Grade≥2R) and 7 antibody-mediated rejections. Five patients underwent antibody removal post-transplant. One patient developed severe graft vasculopathy. Freedom from death or retransplantation was 100%/96%/69% at 1/5/10 years. No graft loss was attributed to BG antibodies. Conclusions: Successful ABOi heart transplantation can be performed at an older age and with higher isohemagglutinin titers than initially assumed and using similar immunosuppressive regimens as for ABO-compatible transplants. Rejection and graft vasculopathy are rare. Persistently low titers of antibodies to the donor BG post-transplant suggest elements of tolerance and/or accommodation.

Original languageEnglish (US)
Pages (from-to)285-292
Number of pages8
JournalJournal of Heart and Lung Transplantation
Issue number3
StatePublished - Mar 2013


  • ABO incompatible
  • antibodies
  • blood groups
  • children
  • heart transplantation
  • immature immune system
  • mechanical circulatory support
  • tolerance

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Transplantation
  • Pulmonary and Respiratory Medicine
  • Surgery


Dive into the research topics of 'ABO-incompatible heart transplantation in early childhood: An international multicenter study of clinical experiences and limits'. Together they form a unique fingerprint.

Cite this