eMedicine Specialties > Pediatrics: Surgery > Transplantation

Heart Transplantation: Treatment

Author: Richard E Chinnock, MD, Medical Director of Pediatric Heart Transplant Program, Professor and Chair, Department of Pediatrics, Loma Linda University School of Medicine and Children's Hospital
Contributor Information and Disclosures

Updated: Nov 7, 2008

Treatment

Medical Therapy

The management of children with serious heart disease is specific to each diagnosis and is discussed in the appropriate eMedicine articles. Issues specifically referable to heart transplantation are discussed here.

Many pediatric patients awaiting heart transplantation can be managed out of the hospital. Evaluate patients on a frequent basis (at least monthly). Pay particular attention to any febrile illness because transplantation in the face of acute infection can be dangerous. Aggressive infection surveillance and treatment is warranted. The issue of vaccination may arise in this setting. Generally, vaccinations, especially live virus vaccines, should be avoided while waiting for transplantation to avoid stimulating the immune system when a donor may become available at any time. However, in a child believed to be capable of safely waiting at least 6 weeks for transplantation, administration of live virus vaccines (if appropriate for age) prior to transplantation is probably better because live virus vaccines are commonly avoided entirely after transplantation.

Surgical Therapy

Attention to detail during the procurement of the donor organ and gentle handling of the donor organ are as important as the implantation of the organ. The donor operation must be tailored to the anatomic needs of the recipient. Recipient anomalies of pulmonary venous connection often require complete resection of the donor left atrium, dividing each donor pulmonary vein separately. In the case of anomalies of systemic venous return, extended removal of the superior vena cava, left innominate vein, and inferior vena cava may be required.

The pediatric cardioplegia solution is usually either the University of Wisconsin solution or Roe solution.

Preoperative Details

Meticulous care of child awaiting transplant is essential to ensure the best possible outcome. The management of children with advanced heart failure is outlined in Heart Failure, Congestive. For patients with ductal dependent physiology, the lowest dose possible of prostaglandin (0.1-0.2 mcg/kg/min) should be used. The authors usually use a peripherally inserted central catheter (PICC) line, with a second heparin lock in place in the advent of sudden loss of the primary intravenous site. Oxygenation must be managed to balance the pulmonary and systemic blood flows. This may require adding nitrogen to the inspired gas mixture to render delivered oxygen at less than a fractional inspired oxygen (FiO2) of 0.21.

An important complication is a significantly restricted interatrial communication. Balloon atrial septostomy or surgical septectomy may be necessary. A protocol that incorporates stenting of the patent ductus arteriosus and pulmonary artery banding has been used in Denver to allow children with hypoplastic left heart syndrome (HLHS) to wait without prostaglandin E (PGE) infusion, even outside the hospital.

Among all children waiting for heart transplantation, the mortality rate prior to transplantation is approximately 15-20%. Mortality during the waiting period for infants with HLHS is significant when the infant has to wait longer than about 3 months, with infants only occasionally surviving until age 6 months. In the group of less critically ill children (United Network for Organ Sharing [UNOS] status II), the pretransplant mortality rate by 12 months is about 10%.

Intraoperative Details

The operative method of transplantation in children with cardiomyopathy is the same as that for adults. A median sternotomy is used to perform thymectomy and to expose the recipient's native heart. If the donor heart is significantly larger than the native heart, the entire left pericardium anterior to the phrenic nerve is removed. Single venous and arterial cannulation is generally used. A standard orthotopic technique using biatrial or bicaval connection is used. Modifications for anatomy specific to congenital heart disease are as follows:

  • For the infant with HLHS, the ductus arteriosus is isolated and cannulated for arterial perfusion through a stab wound in the distal main pulmonary artery. All aortic arch vessels are isolated with loose tourniquets during the initial cooling phase in preparation for reconstruction. Implantation of the allograft is accomplished with systemic hypothermia, performing the atrial anastomoses under low-flow perfusion, with the pulmonary artery clamped and systemic perfusion maintained by means of the arterial cannula positioned in the ductus arteriosus. The aortic arch is then reconstructed under circulatory arrest with the arch vessel tourniquets tightened. The excision of ductal tissue at its entrance into the distal arch is important in providing secure aortic tissue for the anastomosis and to minimize the likelihood of a posttransplant stenosis in this area. The pulmonary artery anastomosis is completed while the patient is rewarmed.
  • Other complex congenital heart anomalies, such as transposition of the great arteries, can often be managed with direct anastomosis if sufficient lengths of donor arterial and venous connections are procured.

Postoperative Details

Management of the child who has undergone heart transplantation is similar to management for any pediatric cardiac surgery. Those details specifically referable to heart transplantation include the following:

  • Prostaglandin therapy: For patients receiving PGE prior to transplantation, continuing for at least 1-2 days and then gradually weaning over 2-3 days to prevent rebound pulmonary hypertension is advisable.
  • Pulmonary hypertension: The donor right ventricle is not tolerant of significant pulmonary hypertension; for this reason, acute graft failure is one of the largest contributors to early mortality. Optimal therapy includes sedation, vasodilator therapy, alkalinization through hyperventilation, inotropic agents with minimal pulmonary vasoconstrictive effects, and inhaled nitric oxide, when available. Sildenafil has also been used in this setting.
  • Pulmonary management: Many children receive donor organs that are larger than their native hearts. This leads to compression of lung parenchyma. Aggressive pulmonary toilet is indicated, and close observation for respiratory compromise is required, especially after the initial extubation.
  • Perioperative immunosuppression: A number of protocols exist for immunosuppression in the perioperative and postoperative period. The following protocol is used at Loma Linda University Children's Hospital:
    • Cyclosporine is begun at 0.1 mg/kg/h intravenously when the donor is identified, stopped during surgery, and restarted after transplantation. This is switched to oral dosing when possible, with a target trough cyclosporine level of 250-300 ng/mL.
    • Methylprednisolone is intravenously administered at a dose of 20 mg/kg every 12 hours for 4 doses.
    • Antithymocyte induction therapy (Thymoglobulin) is administered in recipients older than 30 days at a dose of 1.5 mg/kg/d once daily for the first 5 days.
    • Mycophenolate mofetil (MMF) is intravenously or orally administered twice daily at 500 mg/m2/dose and adjusted as necessary to maintain an MMF level of 2.5-5 mcg/mL and a WBC count of at least 4 X 109/L.
  • Adjunctive therapy: Adjunctive therapy includes intravenous immune globulin at a dose of 2 g/kg administered at 500 mg/kg/d for 4 days, given over 12 hours, beginning right after the transplantation. Ranitidine is administered while the patient is receiving methylprednisolone. Ganciclovir is intravenously administered for 2 weeks in recipients who are CMV positive or who receive a CMV-positive donor. Aspirin at 3-5 mg/kg/d is administered if the platelet count is chronically more than 500 X 109/L.

Follow-up

Close outpatient follow-up is essential to ensure long-term success. The highest risk for complications occurs in the first few months after transplantation; for this reason, the child should remain near the transplantation center for the initial follow-up. The outpatient-testing schedule at Loma Linda University Children's Hospital is as follows:

  • Physician visits are twice weekly for 6 weeks, then less frequently as the rejection-free interval increases. Minimum visit frequency is monthly for the first year and every 3 months thereafter.
  • Echocardiography is performed twice weekly for 4 weeks, then less often as the rejection-free interval increases, and it should be performed at the same time as the routine physician visits thereafter. Full-study echocardiography is performed at 1 month, 3 months, and 12 months to evaluate the aortic arch in patients with arch reconstruction. ECG is performed monthly for the first 3 months, then quarterly until 1 year after transplantation, and then every 6 months thereafter.
  • Chest radiography is performed monthly for 3 months, at 12 months, and then annually.
  • Cyclosporine or tacrolimus trough level is assessed twice weekly for 2 weeks after discharge, weekly for 4 weeks, monthly for the first year, and then every 3 months thereafter. Target cyclosporine levels (with favorable rejection history) are 250-300 ng/mL for 6 months, 200-250 ng/mL for 6-12 months, and then 125-150 ng/mL thereafter. Tacrolimus trough levels are maintained at 10-13 ng/mL for 6 months, 8-10 ng/mL from 6-12 months, and then 5-8 ng/mL thereafter if rejection history is favorable.
  • MMF levels are checked concurrently with calcineurin inhibitor levels. Mycophenolic acid levels are maintained at 2.5-5 mcg/mL. Note that immunosuppression blood level targets are only starting points. Adjustments are needed in the individual child because of rejection history and side effect profile.
  • CBC count with platelets is obtained every 2 weeks for 2 months, then monthly for the first year, and every 3 months thereafter.
  • Levels of basic electrolytes are obtained at the same time as the CBC count for the first year, with complete metabolic profile (including magnesium levels) every 3 months.
  • CMV immunoglobulin G (IgG) titer is assessed at 6 months, 12 months, and then annually until conversion. EBV PCR is assessed every 3 months.
  • HIV and HBsAg tests are obtained at 6 months.
  • Isotopic glomerular filtration rate (GFR) is assessed at 3 months, 12 months, and every year thereafter for patients who undergo transplantation during infancy. Isotopic GFR is assessed every 2 years for patients who undergo transplantation after the first year and for children who are older than 2 years and whose most recent GFR is more than 100 mL/min/1.73 m2.
  • Renal ultrasonography is performed at 3 months, 12 months, and then every other year.
  • Endomyocardial biopsy is obtained annually for those who are newborn to aged 2 years at transplantation; at 1 month, 3 months, 12 months, and annually thereafter for children aged 2-8 years at transplantation; and prior to discharge, at 1 month, 2 months, 3 months, 6 months, 12 months, and annually thereafter for patients aged 9 years or older at transplantation.
  • Coronary angiography is performed annually, starting at the first anniversary of transplantation. Intravascular ultrasonography (IVUS) is performed starting at age 6 years and then every other year unless prior IVUS demonstrated Stanford class 4 findings.
  • All routine vaccinations, except live virus vaccines (eg, oral polio, varicella vaccine, measles-mumps-rubella [MMR]) should be administered, starting as early as 6 weeks after transplantation.

For excellent patient education resources, visit eMedicine's Heart Center. Also, see eMedicine's patient education article Heart and Lung Transplant.

Complications

The most significant causes of death after heart transplantation include early graft failure (either primary graft failure or secondary to pulmonary hypertension), allograft rejection, infection, allograft vasculopathy, and malignancy.

Allograft Rejection

Preventing rejection while avoiding severe infections, renal failure, and cancer is the biggest challenge facing the transplant physician. Immunosuppression strategies follow.

Introduction

In the earliest days of heart transplantation, the therapeutic options available to the clinician for the prevention of allograft rejection were limited. Initial protocols involved total body irradiation. This was shortly followed by the use of azathioprine (AZA), 6-mercaptopurine, and other myelotoxic agents. Steroids were used systematically beginning in the early 1960s. However, consistently successful immunosuppression did not arrive until the introduction of cyclosporine in the early 1980s. The clinician's armamentarium has now expanded to include agents from various categories.

Mechanisms of action

An extensive discussion of important immunosuppressive agents is beyond the scope of this article. Several recent reviews contain more information.

Immunosuppression strategies

Broadly speaking, immunosuppression strategies in pediatric heart transplantation are built around induction versus no induction and double versus triple drug regimens. Note that none of these strategies have been studied in sufficiently large-scale, randomized, controlled studies. Rather, their use has been adopted from adult thoracic and pediatric noncardiac solid organ trials and adapted through use and experience in pediatric heart transplantation.

Induction therapy

The use of monoclonal or polyclonal antibody T-cell–depleting agents (ie, induction therapy) has been a controversial subject for a number of years. Induction therapy was used early in transplantation and then fell out of favor because of concerns about overimmunosuppression with resultant infections and posttransplant lymphoproliferative disease (PTLD). However, interest has been renewed in their use as a means to reduce or eliminate steroid use. Several studies have demonstrated the efficacy of this approach.

In the most recent report from the registry of the International Society for Heart and Lung Transplantation (ISHLT), more than 60% of pediatric patients who received a heart transplant were treated with induction strategies. Broken down by agent, about 40% used polyclonal antibody T-cell–depleting agents, and 20% used interleukin-2 receptor antagonist. At Loma Linda, the authors have used rabbit-derived polyclonal antibody in a steroid-avoidance regimen.

Dual versus triple therapy

Essentially, all regimens start with the foundation of a calcineurin inhibitor—either cyclosporine or tacrolimus (Prograf, FK506). Only one small-scale trial has compared cyclosporine (Neoral, Sandimmune, Gengraf) with tacrolimus in pediatric heart transplantation, demonstrating essentially equivalent efficacy. Even so, the pediatric heart transplant community has gradually shifted toward greater use of tacrolimus. In the ISHLT registry report, the use of tacrolimus at 1 year after transplantation has now surpassed that of cyclosporine. The main advantage of tacrolimus is its lack of cosmetic side effects (hirsutism and gingival hyperplasia). It has greater potency than cyclosporine on a per-milligram basis and is successfully used for patients with recurrent rejection.

Increased incidence of PTLD and posttransplant diabetes is a concern. Newer strategies that incorporate lower target levels have helped greatly with both of these concerns. Oral administration is incomplete and variable, with absolute bioavailability ranging from 17-22% in adults. In children, bioavailability is about 31%, although whole blood concentrations in 31 children younger than 12 years showed that children required higher doses than adults to achieve similar tacrolimus trough concentrations. A high-fat meal reduces mean area under the curve (AUC) by 37%, whereas a high-carbohydrate meal decreases mean AUC by 28%. Peak concentrations are also reduced by 77% and 65%, respectively.

On a more practical note, tacrolimus is not commercially available as a liquid preparation; therefore, tacrolimus solution must be compounded in a local pharmacy, with potential for errors. In addition, tacrolimus is recommended to be administered on an empty stomach, complicating its use in school-aged children, who may have a limited amount of time in the morning before school. Many centers do not strictly adhere to this suggestion, with apparently good results. Whether the results reflect an increased dose to overcome issues with bioavailability is unknown.

At Loma Linda, the authors generally use cyclosporine as the preferred calcineurin inhibitor. Target trough levels (whole blood, monoclonal assay) are 250-300 ng/mL for the first 6 months, 200-250 ng/mL for the next 6 months, and 125-150 ng/mL thereafter if rejection history is acceptable. Tacrolimus is used primarily in certain select high-risk candidates (eg, patients with multiple prior cardiac surgeries, patients with high panel reactive antibody levels African American recipients). The authors also use tacrolimus for patients with recurrent rejection. A significant number of children experience problematic cosmetic side effects, especially children who require orthodontia, in whom gingival hyperplasia is counterproductive.

Antiproliferative agents

Azathioprine (AZA; Imuran) has been the mainstay in this class of agents. However, in the ISHLT registry, mycophenolate mofetil (MMF; CellCept) is now used in approximately 60% of pediatric patients who receive a heart transplant. Again, no prospective studies are available.

Cardiac allograft vasculopathy significantly affects long-term graft and patient survival. In adult cardiac transplant trials, MMF has been shown to decrease the progression of coronary intimal thickness. MMF, like AZA, can induce bone marrow suppression effects. The biggest challenge is the significant risk of gastrointestinal side effects, which affect patient tolerability. A significant advantage is that the drug can be dosed to a therapeutic level.

At Loma Linda, the authors use MMF as part of the primary immunosuppression regimen. The authors start with a dose of 300 mg/m2/d divided twice daily and advance as tolerated to maintain a level of 2.5-5 mcg/mL (measuring mycophenolic acid levels).

Corticosteroids

Oral corticosteroids have been a mainstay of rejection prophylaxis since the early days of transplantation. However, in pediatric heart transplantation, reports from various centers over a number of years have documented effective rejection prophylaxis with steroid avoidance and/or early weaning to zero. Steroid avoidance is believed to require induction therapy. The newer immunosuppressive agents have given more confidence to those who wish to wean to zero. Programs that use steroids typically start with oral prednisone at a dose of 2 mg/kg/d and then wean over the first 3 months to a maintenance dose of 0.1-0.3 mg/kg/d once daily or once every other day.

At Loma Linda, the authors have practiced steroid avoidance from program inception, with oral prednisone only used in the treatment of rejection or in children in whom no other combination is effective or tolerated. This approach has received some validation from the immunology literature, which has demonstrated that chronic glucocorticoid therapy leads to downregulation of cytoplasmic glucocorticoid receptor expression, as evidenced in T lymphocytes.

mTOR inhibitors

The mTOR inhibitor sirolimus (Rapamune) is a newer agent that works synergistically with calcineurin inhibitors. Little published experience in pediatric heart transplantation has been reported, but what is available seems to indicate some usefulness in the management of rejection, renal dysfunction, and calcineurin side effects.

At Loma Linda, the authors have been using sirolimus for recurrent rejection, in children with renal insufficiency (to decrease calcineurin inhibitor dose or to eliminate the calcineurin inhibitor, used in conjunction with MMF), as solo therapy in the first few months after treatment for PTLD, and in children who have coronary intravascular evidence of moderate-to-severe cardiac allograft vasculopathy.

Nonpharmacologic measures

Three additional therapies are worth mentioning. Total lymphoid irradiation has been used in the treatment of recalcitrant rejection. It has become less necessary with the availability of newer immunosuppressive agents. Plasmapheresis has been used either pretransplantation in patients who are highly sensitized or posttransplantation in patients with acute antibody-mediated rejection (AMR) or in whom AMR is anticipated. Photophoresis involves the extraction of lymphocytes from patients who were pretreated with psoralen, treatment with ultraviolet A light, and reinfusion. It has been helpful in the prevention and treatment of recurrent rejection. No reports on its use with children have been published.

Treatment of acute rejection

The mainstay for the treatment of acute graft rejection is high-dose intravenous or oral corticosteroid administration. An oral steroid taper is often used after intravenous treatment. No controlled studies regarding the appropriate dose have been reported.

At Loma Linda, the authors treat acute rejection with intravenous methylprednisolone at a dose of 20 mg/kg/dose (not to exceed 500 mg/dose) twice daily for 8 doses. Uncomplicated rejection diagnosed based on biopsy findings alone may be treated with oral prednisone at a dose of 2 mg/kg/d for 3 days, with a taper to zero over 3 weeks. In patients with recurrent rejection or with acute rejection with hemodynamic compromise, anti–T-cell antibody preparations should be added. The authors use antithymocyte globulin (Thymoglobulin, Sangstat, rabbit-ATG) at a dose of 1.5 mg/kg/d administered by slow intravenous administration over 6 hours. This is given daily for 7-10 days. A lymphocyte profile should be obtained on day 3, with a target absolute CD3 count of less than 200 cells/mL. The use of high-dose intravenous immunoglobulin in the treatment of graft rejection may be beneficial.

An evaluation of the causative mechanisms must accompany the treatment of the rejection episode. If immunosuppressive doses have been faithfully given and if the desired therapeutic levels have been maintained, either the desired level must be increased or the agent must be changed. Noncompliance must be suspected in any late rejection episode, especially with low drug levels and in the adolescent patient.

Diagnosis of rejection

Rejection is diagnosed based on clinical signs and symptoms, echocardiographic changes, and endomyocardial biopsy findings.

Clinical clues to rejection include a decrease in the child's activity or feeding, low-grade fever, persistent resting tachycardia, ventricular ectopy, S3 gallop, tachypnea/dyspnea, hepatic congestion, ileus, and other signs or symptoms of low cardiac output. Echocardiographic criteria for rejection are somewhat controversial but include findings reflective of an increase in left ventricular mass, impairment of systolic and diastolic function, new pericardial effusion, and new mitral insufficiency.

Some have advocated tissue Doppler imaging to improve sensitivity of echocardiographic diagnosis of rejection. Analysis of ECG may have some use, with significant lowering of voltage indicating a risk for rejection. Signal-averaged ECG may reveal an abnormal strain pattern with rejection. Cardiac functional biomarkers have been advocated for the diagnosis of rejection. B-type natriuretic peptides have been used, although their levels widely vary and demonstrate an overlap between normal and rejection. They may be most useful in the emergency room setting, in which a normal value can provide reassurance that rejection is unlikely. 

Gene expression profiling is also under investigation, but its applicability to pediatrics is controversial. Endomyocardial biopsies are the criterion standard and are graded according to the criteria of the ISHLT, with treatment generally occurring only for biopsy samples that demonstrate a 2R (ie, 2 or more foci lymphocytic infiltration with associated myocyte damage) or greater histology.3

Antibody-mediated rejection is becoming increasingly recognized. Preformed antibodies have long been recognized to create the potential for hyperacute rejection in the early posttransplant period. Retrospective crossmatching should be performed, and consideration should be given to plasmapheresis in the setting of a positive crossmatch finding and graft dysfunction. Anti-CD20 monoclonal antibody has also been used in this setting to decrease production of anti-donor antibodies. De novo development of anti–human leukocyte antigen (HLA) antibodies, particularly to class II, have been associated with an increased incidence of allograft vasculopathy. Many centers now test for the presence of C4d on endomyocardial biopsy specimens, especially in the face of graft dysfunction, as a marker of antibody-mediated rejection.

Infection

Infection is an expected complication, with a significant number of recipients experiencing one or more potentially serious infections in the first few months after transplantation. These infections in the early postoperative period usually are bacterial and include wound infections, pneumonia, bacteremia, and urinary tract infections. Cytomegalovirus (CMV) is a significant complication. Pneumocystis carinii infections occur but are less frequent. Other opportunistic infections should be anticipated and aggressively treated when present.

Malignancy

Malignancy, usually PTLD associated with Epstein-Barr virus (EBV) infection, occurs in 2-10% of children. When the histology is low-grade (polymorphous hyperplasia), it usually responds to short-term cessation of immunosuppression. Higher-grade lymphomas are treated with a modified chemotherapeutic regimen that consists of cyclophosphamide every 3-4 weeks for 4-6 months accompanied by anti-CD20 monoclonal antibody (rituximab) for tumors that express CD20. For more information, see Posttransplant Lymphoproliferative Disease.

Clinical protocols are currently being explored to prevent PTLD. These include serial monitoring of EBV polymerase chain reaction (PCR) and intervening with ganciclovir (Cytovene) or valganciclovir (Valcyte) with or without serial infusions of intravenous immunoglobulin in an attempt to decrease the viral load while the patient's immune system develops an adequate response to the infection. In the face of acute EBV infection, the immunosuppression should be minimized as much as possible. However, rejection and graft vasculopathy have recently been suggested as important risks of excessively reducing immunosuppressive medications, especially in patients who have undergone heart transplantation.

Once infected, the EBV PCR viral load counts can widely vary. The development of PTLD is not always accompanied by high PCR counts.

Allograft Vasculopathy

Allograft vasculopathy has emerged as the most important limiting factor for long-term survival. At 10 years after transplantation, as many as 20% of recipients have developed significant allograft vasculopathy. Because the donor heart is denervated, children with graft vasculopathy rarely present with angina. They may have atypical angina such as shoulder or back pain or, more frequently, abdominal pain. They may also present with syncope or sudden death. Significant vasculopathy that causes cardiac function changes and that is diagnosed using coronary angiography is probably best treated with retransplantation.

Other modalities that have been useful in diagnosis include treadmill testing and dobutamine stress echocardiography. Data in adult heart transplantation suggest that calcium channel blockers and 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors may help prevent allograft vasculopathy. Some data in children suggest that the same effect is seen in children. Some transplantation centers treat all children with these agents, while others use them only in high-risk patients.

IVUS has been used extensively to assess coronary artery disease and especially to evaluate different immunosuppressive regimens in adult patients who have received a heart transplant. Abnormalities in IVUS findings have been shown to predict later development of significant cardiac events. Few reports have described the use of this technique in children, but it has been suggested as a more sensitive assessment of graft vasculopathy.

mTOR inhibitors have been shown to decrease the incidence of graft vasculopathy in adults who have received a heart transplant, and one report noted the reversal of disease. mTOR inhibitor use is currently being explored in children.

Nephrotoxicity

Nephrotoxicity is the most import nonlethal complication. Hypertension, metabolic acidosis, and other metabolic abnormalities may be observed with varying frequency. Adjusting the calcineurin inhibitor to the lowest level possible helps ameliorate these problems. Minimizing steroid dosing also helps significantly with hypertension and with issues relating to growth and bone density.

Newer immunosuppressive strategies to minimize nephrotoxicity have used the synergistic properties between calcineurin inhibitors and sirolimus to lower the calcineurin inhibitor dose. A combination of sirolimus and MMF has also been used as a noncalcineurin inhibitor immunosuppressive regimen.

Pulmonary Complications

Chronic respiratory complications are being recognized with increased frequency, with one report noted an incidence of 50% of patients. Bronchiectasis was reported in 17% of patients. Obstructive sleep apnea was diagnosed in 7% of patients. Sirolimus-associated pneumonitis has been described.

Metabolic Abnormalities

Hyperlipidemia is found in a higher proportion of pediatric heart transplant recipients. This seems more common with cyclosporine than with tacrolimus. It is also more common in children who are on chronic steroids, and those children treated with sirolimus. Posttransplant diabetes has also been described and is more common in children treated with tacrolimus and/or steroids.

More on Heart Transplantation

Overview: Heart Transplantation
Workup: Heart Transplantation
Treatment: Heart Transplantation
Follow-up: Heart Transplantation
References
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Further Reading

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Keywords

heart transplantation, cardiac transplantation, hypoplastic left heart syndrome, HLHS, congenital cardiomyopathy, errors in the formation of the heart, cardiac tumors, infections, toxins, cyanosis, tachypnea, tachycardia, dysrhythmias, poor perfusion, feeding intolerance, heart transplant, Ebstein anomaly, Catch-22 syndrome, DiGeorge syndrome, interrupted aortic arch, dilated cardiomyopathy, restrictive cardiomyopathy, hypertrophic cardiomyopathy, pulmonary atresia with intact ventricular septum, transposition of the great arteries, heart block, atrioventricular septal defect, heart failure, cyanosis, tachypnea, tachycardia, dysrhythmias, poor perfusion, feeding intolerance, cardiac arrest

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Contributor Information and Disclosures

Author

Richard E Chinnock, MD, Medical Director of Pediatric Heart Transplant Program, Professor and Chair, Department of Pediatrics, Loma Linda University School of Medicine and Children's Hospital
Richard E Chinnock, MD is a member of the following medical societies: American Academy of Pediatrics, American Heart Association, American Medical Association, American Society of Transplantation, California Medical Association, International Society for Heart and Lung Transplantation, Society for Pediatric Research, Transplantation Society, and Western Society for Pediatric Research
Disclosure: Nothing to disclose.

Medical Editor

Richard G Ohye, MD, Director, Pediatric Cardiac Transplantation, Fellowship Program Director, Pediatric Cardiac Surgery, Assistant Professor, Department of Surgery, Section of Cardiac Surgery, University of Michigan Medical Center
Richard G Ohye, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American College of Chest Physicians, American College of Surgeons, Association for Academic Surgery, International Society for Heart and Lung Transplantation, and Society of Thoracic Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Steve Dunn, MD, Chief, Solid Organ Transplantation, Department of Surgery, Alfred I DuPont Hospital for Children at Wilmington
Steve Dunn, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, American Society of Transplant Surgeons, American Society of Transplantation, and Christian Medical & Dental Society
Disclosure: Nothing to disclose.

CME Editor

Gilbert Herzberg, MD, Assistant Professor, Department of Pediatrics, Section of Pediatric Cardiology, New York Medical College
Gilbert Herzberg, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Chief Editor

Steven R Neish, MD, SM, Director of Pediatric Cardiology Fellowship Program, Associate Professor, Department of Pediatrics, Baylor College of Medicine
Steven R Neish, MD, SM is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, and American Heart Association
Disclosure: Nothing to disclose.

 
 
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