Biomedical subjects

Kirk R Kanter

Publications and source records attributed to Kirk R Kanter.

At least 19 recordsLinked to original sources

PubMed2007

Cerebral near infrared spectroscopy is a reliable marker of systemic perfusion in awake single ventricle children.

Clinical assessment of systemic perfusion in single ventricle patients with parallel circulation can be difficult in the outpatient setting. Near infrared spectroscopy (NIRS) is a noninvasive measure of cerebral oximetry. We measured vital signs, pulse oximetry, and NIRS in 20 single ventricle patients with parallel circulation prior to routine cardiac catheterization. These variables were evaluated to determine the best noninvasive predictor of the superior vena cava saturation (SVC(sat)) as a marker for the adequacy of systemic oxygen delivery. The mean age was 6.7 months [standard deviation (SD), 8.6] and mean weight was 6.5 kg (SD, 2.2). Diagnoses were hypoplastic left heart syndrome (8), tricuspid or pulmonary atresia (10), and double-outlet right ventricle variants (2), all prior to cavo pulmonary anastomoses or complete repairs. Stepwise multiple regression analysis generated a model in which only NIRS was a significant independent predictor of SVC(sat) (p = 0.009). These results support the conclusion that NIRS can be a useful tool to evaluate awake single ventricle patients in the outpatient setting.

Biomarkers↗

PubMed2007

Physician payment for 2007: a description of the process by which major changes in valuation of cardiothoracic surgical procedures occurred.

Throughout the last 3 years, the Society of Thoracic Surgeons (STS) has put forth a major effort towards more accurate valuation of the work performed by cardiothoracic surgeons. The culmination of these efforts was realized on November 1, 2006, when the Centers for Medicare & Medicaid Services published the Final Rule which markedly increased the physician work values for the most frequently performed cardiothoracic surgery procedures. This article recounts the innovative approach taken by the STS during these extended efforts.

Cardiac Surgical Procedures↗

PubMed2006

Reduction in initial ventricular systolic and diastolic velocities after heart transplantation in children: improvement over time identified by tissue Doppler imaging.

BACKGROUND: Tissue Doppler imaging (TDI) is a non-invasive method for measuring ventricular function that can provide insight into the changes in hemodynamics that occur after pediatric heart transplantation. The purpose of this study was to quantify longitudinal changes in myocardial velocities within the first 6 months after transplantation in children. METHODS: Thirteen patients were serially studied (median age at transplant 5.9 years) and compared with controls. Tissue Doppler systolic (S), early (E) and late (A) diastolic velocities were recorded at the tricuspid annulus, mitral annulus and interventricular septum. RESULTS: TDI studies were serially performed during 6 months post-transplantation: <10 days (n = 48); 11 to 30 days (n = 26); 31 to 60 days (n = 13); 61 to 120 days (n = 12); and 121 to 180 days (n = 16). Mean systolic tissue velocities at the tricuspid annulus were 3.8 cm/s (95% confidence interval [CI]: 3.1 to 4.6) at baseline (<10 days) and 6.3 cm/s (95% CI: 4.1 to 8.6) at 6 months post-transplantation (mean increase from baseline: 2.5 cm/s; 95% CI: 0.1 to 4.9). Systolic tissue velocities at the mitral annulus also increased over time (mean change from baseline: 0.9 cm/s; p = 0.02). Early diastolic (E) velocities at the tricuspid annulus and mitral annulus significantly improved over time (p < 0.0001 and p = 0.002, respectively). Systolic and diastolic velocities measured at >121 days after transplantation, however, remained significantly lower than those of normal controls. CONCLUSIONS: TDI demonstrated systolic and diastolic velocities improved during the initial 180 days after heart transplantation. Systolic and diastolic velocities were reduced in children after heart transplantation when compared with controls.

Adolescent↗

PubMed2006

Can pulmonary conduit dysfunction and failure be reduced in infants and children less than age 2 years at initial implantation?

OBJECTIVES: We sought to examine risk factors for pulmonary conduit failure or dysfunction in infants less than age 2 years at initial implantation. METHODS: From 2002 to 2005, 241 children at 17 institutions were discharged alive after initial pulmonary conduit insertion. Initial conduit type was pulmonary allograft in 37%, aortic allograft in 29%, bovine jugular venous valved conduit in 25%, porcine heterograft in 2%, and decellularized allograft in 7%. Parametric hazard analysis determined time-related prevalence and associated risk factors for pulmonary conduit intervention and explantation. Serial echocardiographic measurements after conduit implant were analyzed by mixed regression models. RESULTS: There were 89 first conduit-related interventions after discharge and 37 initial conduit explants were performed. First conduit intervention occurred at a constant rate, with a prevalence of 58% at 3 years from initial implant. Pulmonary conduit explantation (30% at 3 years) was characterized by an early-rising risk, suggesting that catheter-based intervention effectively blunts this early initial risk. Common risk-factors for first conduit intervention and explantation were smaller conduit Z-score and younger age at initial conduit implant, and the presence of pulmonary arborization abnormalities or stenoses. Pulmonary conduit peak gradient and regurgitation progressed nonlinearly in all patients over time. Gradient progressed more rapidly in children with aortic allografts and when initial conduit Z-score was less than +1 or more than +3. Pulmonary conduit regurgitation also progressed more rapidly in children with initial conduit Z-score greater than +3 and in those without jugular venous valved conduits, especially aortic allografts. CONCLUSIONS: Pulmonary conduit durability and hemodynamic function in patients undergoing initial conduit insertion at less than age 2 years can be improved by using pulmonary conduits with Z-scores between +1 and +3.

Blood Vessel Prosthesis↗

PubMed2006

Cost-effectiveness of pediatric heart transplantation.

BACKGROUND: Survival after pediatric heart transplantation has continued to improve. Nonetheless, graft survival is generally <15 years and the costs of transplantation and subsequent immunosuppression are substantial. In the present study, we sought to examine the cost-effectiveness of pediatric heart transplantation. METHODS: Data from 95 pediatric subjects undergoing transplantation at our institution from 1997 through 2004 were reviewed to determine the costs of pediatric heart transplantation. Costs included pre-transplant care, organ procurement, initial hospitalization and follow-up care. Life expectancy was derived from the United Network of Organ Sharing data set. Data were reported as cost per quality-adjusted life-years (QALYs) gained, which were discounted at 3%. Cost-effectiveness was stratified by primary transplantation vs re-transplantation. RESULTS: The mean cost of initial hospitalization and organ procurement was $221,897 per patient for primary transplant and $285,296 per patient for re-transplant. Annual follow-up costs were estimated to be $18,141 in the first year (excluding the first 90 days post-transplant) and $18,480 per year thereafter. Under base-case assumptions, costs per QALY gained were $49,679 for primary transplantation and $87,883 for re-transplantation. Sensitivity analysis yielded a cost-utility range of $44,943 to $57,628 per QALY gained for primary transplantation and $70,834 to $103,661 per QALY gained for re-transplantation. CONCLUSIONS: Costs of primary pediatric heart transplantation are within the accepted range of cost effectiveness. Pediatric heart re-transplantation has higher costs relative to benefits gained owing to shorter graft survival.

Adolescent↗

PubMed2006

Velocity-encoded magnetic resonance image assessment of regional aortic flow in coarctation patients.

BACKGROUND: During primary coarctation repair, collateral blood vessels contribute significantly to distal perfusion. We sought to determine if velocity-encoded cine magnetic resonance imaging (VENC-MRI) could provide insight into anatomy and hemodynamics of collateral flow in patients with unrepaired coarctation. METHODS: Sixteen patients (median age, 6.2 years; range, 1 to 18) with discrete coarctation (65% severe, 29% mild-moderate) and 10 controls (median age, 12.0 years; range, 9 to 15) without left-sided heart lesions were referred for cardiac MRI. Flow volumes were calculated from VENC-MRI images at the coarctation (proximal), diaphragm (distal), and midway between the two points (midpoint). A means model, repeated-measure analysis, was performed for volumes. RESULTS: In coarctation patients, flow volumes increased by 59% (p = 0.0002) from coarctation to diaphragm, primarily between the proximal and midpoint sites (by 77%, p < 0.0001). In controls, flow volumes decreased by 11% along the entire aortic study length. Coarctation volumes were lower than controls by 54% (p = 0.0003) at the proximal site but showed no statistical difference at the midpoint or diaphragm. CONCLUSIONS: Coarctation flow volumes maximally increase in the upper thoracic aorta, but approach normal flow volumes in the lower thoracic region. Arteries arising from mid and lower thoracic level, such as those supplying the anterior spinal cord, may have nearly normal flow if collaterals are present. Velocity-encoded MRI can evaluate flow in patients who have poor collateral circulation to improve surgical planning and decrease neurologic complications of coarctation repair.

Adolescent↗

PubMed2006

Thoracic Surgery Directors Association Award. Cobalt chloride pretreatment attenuates myocardial apoptosis after hypothermic circulatory arrest.

BACKGROUND: Deep hypothermic circulatory arrest (DHCA) causes myocyte injury as a consequence of ischemia and reperfusion. Previous studies have shown that hypoxia or hypoxia-mimetic agents (cobalt chloride [CoCl2] or deferoxamine [DFX]) limit myocyte necrosis by upregulating the transcription factor hypoxia-inducible factor. However, it remains unknown whether these agents attenuate myocardial apoptosis after DHCA. This study tested the hypotheses (1) that hypoxia, DFX, or CoCl2 preconditioning attenuates myocardial apoptosis during DHCA; and (2) that the protective mechanism involves the altered expression of apoptosis regulatory proteins pAkt (antiapoptotic), Bcl-2 (antiapoptotic), and Bax (proapoptotic). METHODS: Anesthetized neonatal piglets were randomly assigned to four groups (n = 6 in a group): control (NaCl injection); hypoxia (pO2 of 30 to 40 mm Hg for 3 hours); DFX injection; or CoCl2 injection. Twenty-four hours later, the animals underwent cardiopulmonary bypass (CPB) and 110 minutes of DHCA. One week after CPB, percentage of apoptotic myocytes (terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling [TUNEL] assay) and expression of the pAKT, Bcl-2, and Bax were assessed by Western blot. RESULTS: Although preconditioning with hypoxia and DFX failed to show a protective benefit, CoCl2 pretreatment significantly attenuated myocardial apoptosis (9.3% +/- 4.1%) versus controls (33.8% +/- 9.7%, p = 0.042). That was associated with increased myocardial pAkt expression (0.19 +/- 0.006 in CoCl2 versus 0.12 +/- 0.008 in control, p < 0.001). The expression of Bcl-2 was also significantly higher in the CoCl2 group (0.15 +/- 0.02) versus control (0.11 +/- 0.01, p = 0.007), whereas Bax expression was lower (0.34 +/- 0.04 versus 0.54 +/- 0.03 for control, p < 0.001). CONCLUSIONS: Preconditioning with CoCl2 before prolonged DHCA in neonatal piglets attenuates myocardial apoptosis by mechanisms involving phosphorylation of Akt, upregulation of the antiapoptotic protein Bcl-2, and decreased expression of the proapoptotic protein Bax.

Animals↗

PubMed2006

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) in pediatric cardiac support.

BACKGROUND: Resuscitation extracorporeal membrane oxygenation (R-ECMO) was introduced at our institution in July 2002. We reviewed the use of venoarterial (VA)-ECMO for cardiac diagnoses at our institution. METHODS: Retrospective analysis of patients on VA-ECMO for cardiac failure was performed. Survival was defined as discharge from hospital. RESULTS: Twenty-seven patients were supported with VA-ECMO (median age, 27 days; range, 1 to 640 days; median weight, 3.8 kg; range, 1.8 to 11.3 kg). Diagnoses were cardiomyopathy-myocarditis (CMM) in 8 (30%), systemic-to-pulmonary artery shunt-dependent single ventricle (SV) in 12 (44%), postcardiotomy for biventricular repair (BiV) in 6 (22%), and arrhythmia in 1 (4%). Sixteen of 27 patients survived (59%). Seven of 8 CMM patients survived (88%); 6 (75%) bridged to cardiac recovery, 1 to transplant (13%), and 1 death (13%). Seven of 12 SV patients survived (58%). The SV ECMO indications: post-Norwood ventricular dysfunction (n = 3, 2 deaths), postoperative cardiac failure (n = 6, 2 deaths), respiratory failure (n = 1, 1 death), and acute shunt occlusion (n = 2, 0 deaths). One of 6 BiV patients survived (17%). The BiV ECMO indications: failure to wean from CPB (n = 3, 3 deaths), postoperative cardiac failure (n = 2, 2 deaths), and pulmonary hypertension (n = 1, 0 deaths). Fifteen patients (56%) underwent cardiopulmonary resuscitation during ECMO cannulation. Eleven of 15 R-ECMO patients (73%) survived versus 5 of 12 non-R-ECMO patients (42%, p = 0.13). Median duration of R-ECMO: 66 hours (range, 18 to 179) versus 145 hours (range, 43 to 986, p = 0.01) for non-R-ECMO. CONCLUSIONS: Resuscitation extracorporeal membrane oxygenation is an appropriate application in pediatric patients with cardiac disease. Single ventricle patients experiencing cardiopulmonary collapse and CMM patients have favorable outcomes. Failure to wean from CPB and postoperative ventricular failure are higher risk indications.

Cardiac Surgical Procedures↗

PubMed2006

Impaired power output and cardiac index with hypoplastic left heart syndrome: a magnetic resonance imaging study.

BACKGROUND: Unfavorable cardiac mechanics in children with hypoplastic left heart syndrome (HLHS) when compared with other single-ventricle defects may affect long-term morbidity and outcome. Using noninvasive phase contrast magnetic resonance imaging (PC MRI), we examined cardiac mechanics in children with HLHS and compared the results to other single-ventricle defects. METHODS: Eighteen children with HLHS and 18 children with other single-ventricle defects were studied after the Fontan operation. Phase contrast MRI scans were obtained perpendicular to the ascending aorta, and flow was quantified using an in-house segmentation and reconstruction scheme. The total power output was determined using the modified Bernoulli equation along with cardiac output and systemic vascular resistance index. RESULTS: Compared with non-HLHS congenital heart defects, children with HLHS had significantly lower power output (1.40 +/- 0.39 versus 1.78 +/- 0.38 W/m2, p < 0.004) and cardiac index (3.15 +/- 0.97 versus 4.09 +/- 1.23 L x Min(-1) x m(-2), p < 0.009) with a concomitant higher systemic vascular resistance index (28.94 +/- 11.5 versus 22.7 +/- 8.53 WU, p < 0.03) despite generating similar systolic blood pressures (112.9 +/- 22.4 versus 115.2 +/- 23 mm Hg, p > 0.05). CONCLUSIONS: Minimally invasive measurements with PC MRI in children with HLHS showed significantly lower power output and cardiac index when compared with other single-ventricle physiologies. Abnormal aortic flow patterns may contribute to power loss and may have long-term survival and morbidity implications associated with the Fontan procedure. Elevated systemic vascular resistance index despite similar blood pressure opens avenues for therapeutic intervention for afterload reduction.

Adolescent↗

PubMed2006

Redo aortic valve replacement in children.

BACKGROUND: Some children who have had an aortic valve replacement (AVR) will need valve re-replacement (redo-AVR). We analyzed our results with 38 redo-AVRs in 30 children. METHODS: Thirty children, aged 2 months to 20 years (mean, 11.5 +/- 5.4 years), underwent 38 redo-AVRs 1 month to 14 years (mean, 4.6 +/- 4.5 years) after previous AVR. Seven children had a second redo-AVR and one had a third redo-AVR (his fourth AVR). Reoperation indication was primarily stenosis in 19, regurgitation in 12, endocarditis in 3, valve thrombosis-emboli in 3, and ruptured aortic aneurysm in 1. The initial valve was mechanical in 26, homograft in 7, xenograft in 4, or a Ross procedure in 1. Sixteen patients (42%) had a previous Konno procedure. RESULTS: The new valve was mechanical (28), homograft (5), xenograft (4), or a Ross procedure (1). Twenty-five valves were upsized on re-replacement. The median valve size was 23 mm (median size increase 4 mm). Twenty-seven operations (71%) included annulus enlargement (16 redo-Konno, 8 new Konno, and 3 Manougian). Twelve children (32%) had concomitant operations including mitral valve repair-replacement (4) and right ventricular outflow tract procedure (5). Three of the 4 hospital deaths were with second or third time redo-AVR. The only death in patients with first time redo-AVR was a patient in cardiogenic shock at the time of operation. CONCLUSIONS: Redo-AVR in children can be performed with reasonable morbidity and mortality. A larger prosthesis can often be placed in these children. Second or third time redo-AVR appears to be riskier. Earlier referral before onset of ventricular dysfunction is warranted.

Adolescent↗

PubMed2006

Failure of surface-modified bypass circuits to improve platelet function during pediatric cardiac surgery.

OBJECTIVE: Surface-modified cardiopulmonary bypass circuits have been shown to improve platelet function and decrease postoperative bleeding after heart surgery in adults. Two surface-modified cardiopulmonary bypass circuits are approved and commercially available for pediatric cardiac surgery. There have been few studies demonstrating the efficacy of these modifications for children. We performed a prospective, randomized trial comparing surface-modified cardiopulmonary bypass circuits to a standard unmodified circuit in pediatric cardiac surgery. METHODS: Sixty-nine children (median 6 months old) undergoing first-time cardiac surgery were enrolled and randomized to an uncoated circuit or one of the two commercially available surface modified circuits for their operation. Blood samples were collected at baseline, on cardiopulmonary bypass, at the end of rewarming, after protamine, and at 18 to 24 postoperative hours. Platelet count, beta-thromboglobulin, and thromboelastography with and without abciximab were measured. Postoperative chest tube outputs and blood product utilization were also analyzed. RESULTS: The platelet counts, beta-thromboglobulin levels, thromboelastographic measures of platelet function, and postoperative bleeding were not significantly different between the surface-modified cardiopulmonary bypass circuit groups and the control group. CONCLUSION: Currently available surface-modified cardiopulmonary bypass circuits do not significantly improve platelet function or clinical outcomes after routine pediatric cardiac surgery.

Blood Platelets↗

PubMed2006

Surgical repair of total anomalous pulmonary venous connection.

The diagnosis of total anomalous pulmonary venous connection (TAPVC) is made when all four pulmonary veins drain anomalously to the right atrium or to a tributary of the systemic veins. It constitutes between 1% and 1.5% of all children with congenital heart disease and can be categorized by the site of drainage into the systemic circulation (supracardiac, 45%; infracardiac, 25%; cardiac, 25%; mixed, 5%). The clinical presentation is different if the pulmonary venous drainage is unobstructed (heart failure, mild cyanosis) or obstructed (respiratory failure, severe heart failure). Surgical management depends on the anatomic type. Obstructed TAPVC requires urgent surgical intervention, whereas unobstructed TAPVC can be dealt with electively; although this is usually operated on once the diagnosis is made. Postoperative pulmonary artery hypertension can be problematic. Recent surgical results with isolated TAPVC have improved, with operative mortality consistently at less than 10%. A particularly challenging group of patients are those with single ventricle physiology and TAPVC with high operative mortality and poor long-term survival.

Adult↗

PubMed2006

Left ventricular aneurysm in a five-week-old child.

Ventricular aneurysms in the pediatric population are rare and no standardized method of treatment exists. We present a case of left ventricular (LV) aneurysm in an infant, 5 weeks after a balloon aortic valvuloplasty for congenital aortic stenosis.

Aortic Valve Stenosis↗

PubMed2005

Total cavopulmonary connection flow with functional left pulmonary artery stenosis: angioplasty and fenestration in vitro.

BACKGROUND: In our multicenter study of the total cavopulmonary connection (TCPC), a cohort of patients with long-segment left pulmonary artery (LPA) stenosis was observed (35%). The clinically recognized detrimental effects of LPA stenosis motivated a computational fluid dynamic simulation study within 3-dimensional patient-specific and idealized TCPC pathways. The goal of this study was to quantify and evaluate the hemodynamic impact of LPA stenosis and to judge interventional strategies aimed at treating it. METHODS AND RESULTS: Simulations were conducted at equal vascular lung resistance, modeling both discrete stenosis (DS) and diffuse long-segment hypoplasia with varying degrees of obstruction (0% to 80%). Models having fenestrations of 2 to 6 mm and atrium pressures of 4 to 14 mm Hg were explored. A patient-specific, extracardiac TCPC with 85% DS was studied in its original configuration and after virtual surgery that dilated the LPA to 0% stenosis in the computer medium. Performance indices improved exponentially (R2>0.99) with decreasing obstruction. Diffuse long-segment hypoplasia was approximately 50% more severe with regard to lung perfusion and cardiac energy loss than DS. Virtual angioplasty performed on the 3-dimensional Fontan anatomy exhibiting an 85% DS stenosis produced a 61% increase in left lung perfusion and a 50% decrease in cardiac energy dissipation. After 4-mm fenestration, TCPC baffle pressure dropped by approximately 10% and left lung perfusion decreased by approximately 8% compared with the 80% DS case. CONCLUSIONS: DS <60% and diffuse long-segment hypoplasia <40% could be considered tolerable because both resulted in only a 12% decrease in left lung perfusion. In contrast to angioplasty, a fenestration (right-to-left shunt) reduced TCPC pressure at the cost of decreased left and right lung perfusion. These results suggest that pre-Fontan computational fluid dynamic simulation may be valuable for determining both the hemodynamic significance of LPA stenosis and the potential benefits of intervention.

Angioplasty↗

PubMed2005

Redo mitral valve replacement in children.

BACKGROUND: Despite excellent results with current techniques of mitral valve repair, some children still require mitral valve replacement (MVR). Of necessity, a certain percentage of these children need valve rereplacement (redo MVR). METHODS: Of 82 MVRs at our institution since 1988, 22 were redo MVRs in 21 children aged 1.4-21 years (mean 9.8 +/- 5.6 years). Interval from initial MVR was 1 month to 18 years (mean 5.8 +/- 4.9 years). Reoperation indication was primarily stenosis in 13 (usually pannus formation), regurgitation in 4, valve thrombosis or embolism in 4, and endocarditis in 1. The initial valve was mechanical in 18 and xenograft in 4. RESULTS: During redo MVR, 8 of 22 (36%) patients had additional procedures including left ventricular outflow tract obstruction relief or aortic valve replacement in 4 and tricuspid valve repair in 2. The new mitral valve was mechanical in 20 and xenograft in 2. Median valve size increased from 21 mm to 25 mm although 7 valves were not upsized on rereplacement (average valve size increase was 3.3 +/- 1 mm). Only 2 patients (9%) needed a new pacemaker. There were no hospital deaths. Six children developed end-stage heart failure and underwent successful cardiac transplantation 3 to 32 (mean 12.1 +/- 10.0) months, postoperatively. On follow-up of 1 month to 7.7 years (mean 2.5 +/- 2.3 years) there has been only one late death of an unrecognized coronary artery anomaly. CONCLUSIONS: Redo MVR in children can be performed safely with low morbidity and mortality. A larger prosthesis can often be placed in these children. A surprisingly high percentage of patients eventually require transplantation, perhaps reflecting unnecessary delay in referral for redo MVR.

Adolescent↗

PubMed2005

Pravastatin therapy is associated with reduction in coronary allograft vasculopathy in pediatric heart transplantation.

BACKGROUND: Hydroxymethylglutaryl CoA reductase inhibitors (statins) have been demonstrated to reduce the risk of developing coronary allograft vasculopathy (CAV) following heart transplantation in adults and are used routinely in many centers. CAV and lipid abnormalities have been reported to be less prevalent in pediatric heart transplant recipients. It is not known whether statins reduce the risk of CAV in this population METHODS: A retrospective review was performed to analyze the risk factors for developing CAV following pediatric heart transplantation with particular attention to the impact of pravastatin therapy. The study population was comprised of 129 pediatric patients who underwent 142 heart transplants at our institution from 1988 to 2003. The outcome variable was freedom from CAV, CAV being determined by coronary angiography or autopsy. RESULTS: CAV was identified in 25 recipients at a median of 3.7 years after transplantation. There were 331 patient-years of pravastatin therapy. Pravastatin therapy resulted in a reduction in total cholesterol levels, 162 +/- 29 to 137 +/- 20 mg/dl, p = 0.01. In multivariate analysis the use of pravastatin was associated with a lower incidence of CAV (p = 0.03), whereas an increased frequency of late rejection (p = 0.003) and earlier year of transplantation (p = 0.04) were associated with increased risk of CAV. CONCLUSIONS: The routine use of pravastatin was associated with a lower risk following pediatric heart transplantation. Further studies into the relationship between lipid abnormalities, inflammation and rejection, and the development of CAV in children are warranted.

Adolescent↗

PubMed2005

OKT3 treatment in refractory pediatric heart transplant rejection.

BACKGROUND: The anti-lymphocyte monoclonal antibody OKT3 has been shown to be effective in the management of steroid-resistant and/or fulminant heart transplant rejection in adults. In addition, some studies suggest that OKT3 may have a role in the management of transplant coronary artery disease (TxCAD). To date, there are limited data regarding the use of OKT3 treatment of refractory rejection or graft failure in children. Our study examines OKT3 treatment in steroid-resistant rejection, rejection with hemodynamic compromise, and TxCAD in children. METHODS: Thirty-eight patients received 53 courses of OKT3 for treatment of rejection and/or graft dysfunction. Primary indications for OKT3 were steroid-resistant rejection (n = 27), rejection with hemodynamic compromise (n = 22), and TxCAD (n = 4). Resolution of rejection was considered absence of biopsy-proven rejection (< grade 2) or resolved TxCAD. RESULTS: OKT3 use in steroid-resistant rejection was associated with a lower incidence of rejection in the 3 months after OKT3 than 3 months before OKT3, median rejection episodes of 2.5 vs 0, p < 0.0001. In rejection with hemodynamic compromise, 20 subjects (91%) demonstrated improved hemodynamics after OKT3 and survived to hospital discharge. The use of OKT3 treatment for TxCAD failed to demonstrate resolution or improvement in angiographic TxCAD in any subject. Only 5 OKT3 treatment courses were stopped secondary to severe adverse side effects. CONCLUSIONS: OKT3 treatment in refractory pediatric heart transplant rejection is efficacious in acute rejection. OKT3 management in pediatric TxCAD is less clear, with no proven benefit identified in this study. OKT3 use in pediatric refractory heart rejection has significant side effects, but is tolerable and safe with close monitoring.

Adolescent↗

PubMed2005

Disparities in outcome for black patients after pediatric heart transplantation.

OBJECTIVE: To examine the relationship of black race to graft survival after heart transplantation in children. STUDY DESIGN: United Network for Organ Sharing records of heart transplantation for subjects <18 years of age from 1987 to 2004 were reviewed. Analysis was performed using proportional hazards regression controlling for other potential risk factors. RESULTS: Of the 4227 pediatric heart transplant recipients, 717 (17%) were black. The 1-year graft survival rate did not differ among groups; however, the 5-year graft survival rate was significantly lower for black recipients, 51% versus 69%, P < .001. The median graft survival for black recipients was 5.3 years as compared with 11.0 years for other recipients. Black recipients had a greater number of human leukocyte antigen mismatches, lower median household income, and a greater percentage with Medicaid as primary insurance, P < .001, P < .001, and P < .001. After adjusting for economic disparities, black race remained significantly associated with graft failure, odds ratio = 1.67 (95% CI 1.47 to 1.87), P < .001. CONCLUSIONS: Median graft survival after pediatric heart transplantation for black recipients is less than half that of other racial groups. These differences do not appear to be related primarily to economic disparities.

Adolescent↗