Cardiac Re-transplantation in Pediatrics: a Multi-Institutional Study

Background: Cardiac re-transplantation (re-Tx) among pediatric recipients remains controversial. The purpose of this study is to use the Pediatric Heart Transplant Study (PHTS) database to investigate the incidence of re-Tx and analyze the risk factors and outcomes after transplantation among children. Methods: The PHTS database was reviewed for all subjects ≤18 years of age at the time of primary transplant and re-Tx from January 1, 1993 through December 31, 2004. Multivariate analyses in the hazard-function domain were used to identify risk factors for re-Tx and for mortality after re-Tx. Results: Risk factors for re-Tx include ventilator support, African-American ethnicity and elevated creatinine. Patient survival was inferior to that after primary transplantation (PTx) with 1-, 3- and 5-year survival probability after re-Tx of 80%, 69% and 60%, respectively (p = 0.04). Patients re-transplanted for graft coronary artery disease fared better than those re-transplanted for early graft failure. A shorter time period between PTx and re-Tx was a significant risk factor for survival according to univariate analysis. However, risk factors for death after re-Tx by multivariate analysis included only early graft failure and rejection during PTx. Conclusions: Survival after pediatric re-Tx is inferior to that after PTx. Re-transplantation for graft failure and rejection are associated with high relative risks for death. Given the limitations of donor availability, re-Tx for early graft failure and rejection appear contraindicated but appears acceptable for those who have survived ≥1 year after their PTx, especially those with graft coronary artery disease.