Heart Transplantation in Infants and Children - Indications, Surgical Techniques and Special Considerations

For some children with severe congenital malformations of the heart or end-stage myopathic processes, cardiac replacement offers the only hope of survival. The evolution of this treatment began in the late 1960s when Kantrowitz performed a heart transplant in a 16-day-old infant with tricuspid atresia[1]. Not long after that, Cooley performed a combination heart-lung transplant in a 2-month-old infant with an atrioventricular canal and pulmonary consolidation with pneumonia[2]. Neither of these infants survived their hospitalization, and in the 1970s fewer than 15 transplants in children were performed. The introduction of cyclosporin and the pioneering work of Bailey and associates at Loma Linda in neonatal transplantation were two significant developments of the 1990s which contributed to a steady increase in the volume of transplantation in children. According to the Registry for the International Society for Heart and Lung Transplantation[3] the number of children transplanted has plateaued since 1990 at 280–300 per year. Although heart transplantation (HTx) is a generally accepted therapy for children with medically refractory heart failure, controversies exist, such as the appropriateness of HTx for children with hypoplastic left heart syndrome. While it is true that HTx in children has been a direct extension from the experience gained in adults, there are substantial differences in practice from the standpoint of indications, surgical techniques, implications of immunosuppression on growth and response to infectious agents, and anticipated survival. This chapter will review the indications for HTx, the surgical techniques involved, the post-transplant management, and the results in children based on the published literature as well as the author’s personal experience.