5.9 Cardiac Transplant in Children Flashcards
Q9 — Cardiac transplantation in children
A 13-year-old child is listed in the cardiac theatre for a heart transplantation
for end-stage heart failure.
a) What are the indications for cardiac transplantation in children?
● Dilated cardiomyopathy
(idiopathic or associated with metabolic,
neuromuscular, infection, viral and genetic disorders, and drugs) —
the most common indication for a cardiac transplant in children.
● Hypertrophic cardiomyopathy,
restrictive cardiomyopathy (rare),
noncompaction cardiomyopathy.
● Congenital heart disease —
single or biventricular system.
● Retransplantation.
b) Name four factors that are important in organ allocation with regards to transplantation.
● ABO blood compatibility.
● Size matching
(donor-recipient weight ratio — DRWR)
(between 0.7 to 2 is better).
● Sex-matched transplants.
● Human leukocyte antigen (HLA) matching;
panel reactive antibody (PRA) test.
c) What factors would you consider during induction of
anaesthesia in this child?
● Patients receiving mechanical support —
ventricular assist device
(pulsatile or centrifugal type) —
to be continued.
● If there is no support,
this is a high risk and very cautious
induction is needed.
● Cardiac surgeons and perfusion
team to be ready if needed.
d) How would you manage intraoperatively?
● Anticipate and prepare for
difficult central venous access.
● Prepare for haemodynamic
instability during reperfusion.
● Prepare for haemorrhage and instability.
● Prepare to support the transplanted heart mechanically and pharmacologically.
e) What immunosuppressant therapies are you aware of for induction therapy and maintenance therapy?
● Induction —
antithymocyte antigen is the
preferred agent in children;
others include interleukin-2 antagonist
(basiliximab) or
high-dose
methylprednisolone.
● Maintenance —
1 Calcineurin inhibitor (tacrolimus)
2 Cell cycle inhibitor (mycophenolate mofetil)
3 Short-term course of oral steroids (prednisolone).
f) What are the complications that can occur after
transplantation?
● Primary graft failure —
low cardiac output syndrome in the early
hours or days post-transplant.
● Rejection — acute cellular rejection (ACR)
in the first 6 months posttransplant,
T-cell mediated,
or antibody-mediated rejection (AMR)
which presents later, humoral-mediated.
● Cardiac allograft vasculopathy —
a leading cause of death in the
medium- to long-term.
● Infection —
CMV, EBV, bacterial.
● Malignancy —
post-transplant lymphoproliferative disease (PTLD).
g) If this child has a successful transplant and presents to you for an elective surgery at a later date, what factors would you consider
● Elective —
discussion with the transplant centre if appropriate.
● Emergency —
urgent consult with the transplant centre;
echocardiography locally before discussion.
● Find out if the child is compliant with immunosuppressant therapy.
● Clinical status of the child.
● Reasonable differential diagnosis.
● Due to immunosuppressive drugs,
there can be fewer obvious signs of
infection or impaired renal function — be aware
