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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 1  |  Issue : 1  |  Page : 78-81

Pediatric heart transplantation in India: Transplantation of an adult heart in a child


1 Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
2 Department of Cardiothoracic Surgery, All India Institute of Medical Sciences, New Delhi, India
3 Department of Cardiac Anesthesia, All India Institute of Medical Sciences, New Delhi, India
4 Department of Organ Retrieval Banking Organization, CN Centre, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication22-May-2015

Correspondence Address:
Prof. Balram Airan
Department of Cardiothoracic Surgery, Room 5, 7th Floor, CN Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2395-5414.157582

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  Abstract 

After the first successful adult heart transplant in India at All India Institute of Medical Sciences, in 1994, we did our first pediatric heart transplant in 2015. An adult heart was successfully transplanted into a 10-year-old child. The steps from planning to the execution of the surgery and successful discharge of the patient are hereby discussed.

Keywords: Adult, heart transplant, India, pediatric


How to cite this article:
Seth S, Hote M, Chauhan S, Chandra D, Ganeshan K, Maikhuri R, Kumar M, Kothari SS, Airan B. Pediatric heart transplantation in India: Transplantation of an adult heart in a child. J Pract Cardiovasc Sci 2015;1:78-81

How to cite this URL:
Seth S, Hote M, Chauhan S, Chandra D, Ganeshan K, Maikhuri R, Kumar M, Kothari SS, Airan B. Pediatric heart transplantation in India: Transplantation of an adult heart in a child. J Pract Cardiovasc Sci [serial online] 2015 [cited 2021 Apr 23];1:78-81. Available from: https://www.j-pcs.org/text.asp?2015/1/1/78/157582

The first heart transplant took place in 1966 [1] and India performed the first successful heart transplant in 1994. [2] The transplant program in India has been slow to take off due to the lack of donor hearts and the expenses involved with the transplant processes and the post transplant care. In recent years, there has been a revival of interest in heart transplantation with a number of new centers starting transplant programs and better coordination between the organ donation and retrieval processes. While adult transplant programs have started, there is little published data available on pediatric heart transplantation in India. Often, heart transplantation for children is performed after multiple palliative operations and success depends on the recognition of abnormalities in their situs, systemic venous return, pulmonary venous return, and great vessels. There is often a size mismatch between the donor and the recipient vessels which needs to be compensated by surgical techniques. We report a patient where an adult heart was transplanted into a child successfully.


  Pretransplant Work-up Top


The patient, a 10-year-old girl, presented with symptoms of progressive shortness of breath for the last 4 months. She was in gross congestive heart failure with hepatomegaly, jaundice with a bilirubin of 10 mg/dl though the liver enzymes were near normal. She was also found to have a beta thalassemia trait with mild pallor (Hb = 9 g/dl). She was stabilized with inotropes and diuretics. Two-dimensional transthoracic echocardiogram showed a left ventricular ejection fraction of 10% with an end-diastolic dimension of 61 mm. Her weight was 23 kg. She underwent an intracoronary stem cell implantation, followed by immunosuppressive therapy with no improvement. She was then listed for a heart transplant.

Limited workup could be done for a heart transplant since she was sick. Serology samples for IgG levels of cytomegalovirus (CMV), herpes simplex virus, hepatitis B virus, hepatitis C virus and HIV were sent, but the results become available only after the surgery. CMV titers for IgG were high, the rest were normal. Imaging studies (magnetic resonance imaging of the brain, computed tomography chest and ultrasound abdomen) could not be done since she was sick. The liver function was deranged and with a bilirubin of 10 mg/dl, she was considered to be high-risk candidate for a heart transplant. The transplant option came on 2 nd January 2015. After careful evaluation, the transplantation took place on 3 rd January 2015.

Issues for transplanting an adult heart into a child with raised bilirubin

  • The first issue was whether the heart of 26-year-old would fit into the chest of 10 years old?


The first step to resolve this issue was the echocardiogram of the donor. The echocardiogram of the donor was normal, and the left ventricle end-diastolic dimension was 53 mm. Since the child's own heart [Figure 1] had dilated to a left ventricular end-diastolic dimension of 61 mm, it was felt that the donor heart [Figure 2] would fit into the thoracic cavity of the recipient.
Figure 1: Recipient echocardiogram.


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Figure 2: Donor heart echocardiogram.


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The weight of the child was 23 kg, and the donor was 55 kg (41% mismatch). In terms of weight, this was a significant mismatch, but in terms of chest cavity size, the heart size appeared to match.

  • The second issue which arose was the high bilirubin. Since the bilirubin was high, and the liver enzymes were normal, it was felt that the hyperbilirubinemia was congestive.


Taking all the issues together, the decision was taken to offer a high-risk heart transplant to the patient.


  The Transplant Process Top


The pretransplant induction included cyclosporine (3 mg/kg) and azathioprine (4 mg/kg) given orally before surgery. Two surgical teams were constituted, the first for harvest of the donor heart. After the declaration of brain death and completion of legal formalities, patient's sternotomy was done, and the heart inspected for any abnormalities andinjuries. When it was found to be healthy and appropriate sized, the recipient team was informed. For the donor heart, the superior vena cava (SVC) and inferior vena cava (IVC), aorta and pulmonary arteries were dissected and freed to be excised later. Heart was preserved by administration of 2 L of custodiol solution (bretschneider solution) to the heart. Meticulous preservation was done using cold saline solution.

On the confirmation of a suitable heart, anesthesia was induced for the recipient, and sternotomy was done. High aortic Argyle (Covedien) and angled venous cannulae (SVC - 22# RMI, IVC 24# RMI) were placed to institute cardiopulmonary bypass (CPB). Patient was cooled to 32°C. Recipient heart was excised. By this time, the donor heart had been brought with a cold ischemia time of 20 min. Orientation of explanted-heart vascular structures was done. Sequential anastomosis of the donor heart was done to the recipient bed starting with left atrial cuff, IVC, SVC, pulmonary artery and the aorta. There was 20-30% discrepancy in the diameter of all of these structures between the donor heart and recipient bed structures. Surgical suturing was appropriately modified. Cheating maneuver and slitting of recipient aorta and pulmonary artery were done to accommodate for these differences. After 60-min of aortic cross-clamp time (counted from the time of donor harvest), a repeat dose of 1 L cardioplegia (custodiol solution) was administered to maintain adequate myocardial preservation. Total aortic cross-clamp time was 81 min.

The patient was slowly weaned off CPB (total CPB duration 142 min). A pulse of methyl prednisolone (250 mg) was given.


  Posttransplant Management Top


The child was given two more doses of pulse methyl prednisolone 8 h apart over the next 24-h. After 24-h cyclosporine and azathioprine was given and intravenous methyl prednisolone was continued for the initial period at 1 mg/kg and then switched to oral prednisolone for a period of 3 weeks after which gradual tapering of steroids was started. Along with the immune suppression, co-trimoxazole (80/400 mg tablet) and valganciclovir (450 mg) were given every 3 rd day and then increased to alternate day. Voriconazole (100 mg) was given every alternate day and then increased gradually to daily. Over the postoperative period, the liver functions were monitored very carefully, and the bilirubin levels fell gradually and as they fell, the doses of various drugs could be adjusted better especially valganciclovir and voriconazole which are hepatotoxic.

Monitoring of the ventricular function was done by echocardiography, and an endomyocardial biopsy was done at 3 weeks to look for rejection. The biopsy showed no rejection. A team from the hospital visited the home of the child and advice was given regarding the hygiene and other precautions to be taken posttransplant especially in the setting of immune suppression and prevent infections. Once these precautions had been implemented, and the house was deemed appropriate, the patient was discharged after 3 weeks of hospital stay. At the first visit after discharge, the child was doing fine.


  Discussion Top


The transplant program in India started in 1994. Adult heart transplant has now started increasing, but pediatric heart transplant in India is still a new area. There are a number of issues which need to be considered and which we will discuss in relation to this case.

Indications for the heart transplant include patients with end-stage heart failure but exclude a bilirubin as high as 10 mg/dl. We took up this patient because we felt that the hyperbilirubinemia with an insignificant rise in liver enzymes was due to congestive heart failure. Liver dysfunction becomes an issue after surgery also because many of the prophylactic drugs to be used after surgery, including co-trimoxazole, voriconazole, and valganciclovir are hepatotoxic. We started these drugs at very low doses in the patient and as the bilirubin came down buildup the doses to therapeutic levels, keeping a close watch on the hepatic function.

The regime that we are currently using for the immune suppression includes cyclosporine, azathioprine, and prednisolone. Later we plan to switch to mycophenolate and taper the steroids. The doses have been adjusted by body weight.

With regards matching the donor heart size to the recipient size, the ideal recommendation is to match within 20% of the weight. In pediatric transplants sometimes the mismatch can be as much as 3 times. [3] In this case, the mismatch was significant. The workaround that we used was to measure the heart size; the donor heart size as measured on an echocardiogram was as big as the heart size the recipient's had become on dilatation. The operating surgeon also removed the recipient heart after matching the cavity to the donor heart.

The long-term survival in children is good and excellent 10 years survival data are available. [4] Late complications and the long-term effects of immunosuppression need to be anticipated and addressed as they arise. [5],[6],[7]

Besides the medical issues discussed, there is a lot of other support which has to be provided to these patients. Many of these patients are from poor socioeconomic strata. Financial assistance needs to be given by government agencies whenever possible. Even if that is not possible, hospitals can attempt to provide some of the expensive medications to the patients whenever possible and defray some of the cost of the treatment. The surgery itself is expensive, and many of the hospitals providing this service are in the private sector.


  Conclusion Top


Careful planning leads to the successful transplant of an adult heart to a child. The medical expertise is available in India to make the heart transplant program a success, and we need to put in more efforts to coordinate the donor and recipient programs.

 
  References Top

1.
Barnard CW. A human cardiac transplant: An interim report of a successful operation performed at Groote-Schur Hospital, Cape Town. S Afr Med J 1967;41:1271.  Back to cited text no. 1
    
2.
Venugopal P. The First Successful Heart Transplant In India. Natl Med J India 1994;7:213-5.  Back to cited text no. 2
    
3.
Sethi GK, Lanauze P, Rosado LJ, Huston C, McCarthy MS, Butman S, et al. Clinical significance of weight difference between donor and recipient in heart transplantation. J Thorac Cardiovasc Surg 1993;106:444-8.  Back to cited text no. 3
    
4.
Kirklin JK, Young JB, McGiffin DC. Heart Transplantation. Philadelphia: Churchill Livingstone; 2002.  Back to cited text no. 4
    
5.
Bando K, Konishi H, Komatsu K, Fricker FJ, del Nido PJ, Francalancia NA, et al. Improved survival following pediatric cardiac transplantation in high-risk patients. Circulation 1993;88:II218-23.  Back to cited text no. 5
    
6.
Bourge RC, Naftel DC, Costanzo-Nordin MR, Kirklin JK, Young JB, Kubo SH, et al. Pretransplantation risk factors for death after heart transplantation: A multiinstitutional study. The Transplant Cardiologists Research Database Group. J Heart Lung Transplant 1993;12:549-62.  Back to cited text no. 6
    
7.
Mitchell MB, Campbell DN, Clarke DR, Fullerton DA, Grover FL, Boucek MM, et al. Infant heart transplantation: Improved intermediate results. J Thorac Cardiovasc Surg 1998;116:242-52.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2]



 

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