Rejection management and long-term surveillance of the pediatric heart transplant recipient: The Loma Linda experience

At Loma Linda University Medical Center, 210 heart transplant procedures have been performed on 207 newborns, infants, and children since 1985. Actuarial survival rate at 5 years is 72% for the entire population and 82% for those receiving a transplant during the first month of life. These patients have been managed with a regimen that minimizes long-term steroid use and emphasizes the noninvasive diagnosis of rejection. This article describes in some detail the mechanics of this process. In addition, the rejection history of 154 children undergoing transplantation from 1989 through 1992 was reviewed. The average number of rejection episodes was 1.67 (standard deviation 1.65; median, 1; mode, 0). The vast majority of rejections occur in the first 3 months after transplantation. Long-term freedom from rejection was 19% for newborn recipients, 42% for infants, 25% for older children. Donor/recipient mismatch for gender, race, blood type, Rh factor, and HLA typing did not correlate with rejection history. Older age at transplantation and cytomegalovirus disease were correlated with more frequent rejection episodes. Five patients had posttransplantation coronary artery disease. This was strongly correlated with greater rejection frequency and death from rejection. In addition, there was a trend toward less posttransplantation coronary artery disease with antibody induction therapy, younger age at transplantation, and absence of cytomegalovirus disease. An evaluation of the medium-term follow-up of children undergoing heart transplantation indicates that excellent results can be obtained with a rejection management and surveillance protocol that emphasizes both the minimal use of long-term oral steroids and noninvasive techniques for diagnosing rejection.