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The relationship between nutritional status and oral aversion (OA) in children listed for heart transplant (HT) is understudied. Single center retrospective review of pediatric HT recipients from 1/1/2014-3/1/2021. Those who had re-HT, multi-organ transplant, a genetic syndrome or did not survive the HT hospitalization were excluded. Demographics, anthropometric and nutritional data was collected from HT listing (HTL) through at least 3 months post-HT. Malnutrition was defined by the ASPEN guidelines, as weight for age, height for age, or BMI for age z-scores ≤ -2. OA was defined as needing supplemental feeds to meet estimated caloric needs; excluding those who were NPO for medical reasons like aspiration. Of 104 patients, 30 (29%) needed supplemental feeds at HTL, 36 (35%) at HT and 35 (34%) 3 months post-HT. The average duration of feeds from HTL to HT was 114 ± 16 days. Younger patients were more likely to need supplemental feeds at HTL (P =0.01) and HT (P <0.01). Risk factors for OA at 3 months included younger age (P <0.001), 1A Status at HTL (P=0.01) and HT (P <0.01), total list days (P =0.03), malnourishment at HTL (P =0.01) and HT (P <0.01) and needing supplemental feeds at HT (P <0.001). VAD support did not mitigate supplemental feeds 3 months post-HT (P =0.31). Approximately 1/3 of children require supplemental feeds at HTL which persists through 3 months post-HT. Risk factors for post-HT OA include status 1A, malnourishment and need for supplemental feeds at HTL. Patient education for those at risk should include expectations regarding the need for ongoing supplemental feeds post-HT. [ABSTRACT FROM AUTHOR]

The TEAMMATE Trial is studying everolimus (EVL) with low-dose tacrolimus (LDTAC) vs. standard tacrolimus (TAC) with mycophenolate (MMF) in a randomized trial in children enrolled at 6 months post-heart transplant. Since therapeutic levels are correlated with lower rejection rates, we sought to describe the immunosuppressant drug level monitoring experience in the trial to date. All children in the TEAMMATE Trial remaining on assigned therapy as of August 2021 were included. Drug levels were obtained at 0, 3, 6, 9, 12, 18, 24, & 30 months post-randomization. Formulation, time to therapeutic level, and number of dose adjustments were tracked at each study visit. Stability was assessed by the coefficient of variation (CoV) (SD/mean). Adherence was assessed by the % of levels within range; and the SD of levels divided by therapeutic window (lower values indicating better adherence). Independence of all levels was assumed in analysis. A total of 211 children were randomized to either EVL/LDTAC (n=107) or usual care TAC/MMF (n=104). After randomization, a therapeutic level was achieved in 94% (EVL) & 91% (MMF). Liquid formulation was used in 37% of EVL subjects. Median time to a therapeutic level for EVL was 10 (tablet) & 11 (liquid) days. The CoV was lower for TAC (36%), EVL (47%), & LDTAC (52%), compared to MMF (103%). Drug levels were in target range 80% (EVL), 20% (MMF), 55% (LDTAC), & 54% (TAC) of the time (Figure). The SD of levels divided by therapeutic window was lowest for EVL (44%), compared to TAC (94%), LDTAC (112%), & MMF (158%). In response to these levels, dose changes were made in 13% (EVL) & 18% (LDTAC) in the EVL/LDTAC group (16% combined) and in 27% (TAC) and 11% (MMF) in the control group (22% combined). EVL achieves stable target levels more frequently than MMF, LDTAC or TAC, likely due to decreased trough level variability and its wider therapeutic window. Fewer dose adjustments have been required for the EVL/LDTAC regimen compared to TAC/MMF. [ABSTRACT FROM AUTHOR]

Cardiac re-transplantation (reTX) in pediatrics remains a rare occurrence, representing only 2% of all pediatric heart transplants (HT). The purpose of this study was to describe the pre-transplant characteristics, waitlist outcomes and post-HT outcomes for reTX at our center. Retrospective review of all patients listed for heart transplantation (HT) from 1/1/2014-10/18/2021. Pre-transplant characteristics and post-transplant outcomes are compared to primary HT. Of 215 total listings, 14 (7%) were for reTX. Of these, 1 (7%) died on waitlist, 1 (7%) remains listed and 12 (92%) survived to reTX, at a median of 140 (62, 454) waitlist days and 7 (4,11) years after primary HT. Three (21%) were bridged to reTX with a ventricular assist device (VAD). One patient received a concurrent kidney transplant. When compared to primary HT, reTX patients were older at listing and transplant (P= 0.01 and 0.008) and less likely to be status 1A at transplant (42% vs. 70%, P= 0.05). Post transplant tracheostomy and dialysis were more common after reTX than primary transplant, though not statistically significant (Table 1). At a median follow up of 667 (364, 1330) days, 9 (75%) reTX and 83% primary HT patients were still alive (P=0.2), (Figure 1). We describe the retransplant experience in a contemporary single center cohort. Pre-HT characteristics are similar, though reTX patients are more often transplanted from a lower UNOS listing status. Long-term outcomes of patients with reTX were not significantly worse than primary HT in this cohort. Patients and families should be counseled at time of listing for reTX complications including tracheostomy and dialysis. [ABSTRACT FROM AUTHOR]

Although dual-drug immunosuppression is standard for rejection prophylaxis in pediatric heart transplant (HT), single-drug immunosuppression (monotherapy) may be sufficient for certain patients. We describe the experience with monotherapy at a single institution. Retrospective review of HT patients at a single pediatric transplant center who underwent HT between from 1/2001- 12/2020 and were treated with calcineurin-inhibitor monotherapy for > 1 month. Patients were transitioned to monotherapy per primary clinician due to concerns for over-immune suppression or post-transplant lymphoproliferative disorder (PTLD). Clinical characteristics and patient outcomes were analyzed. During the study period, 12/333 (3.6%) patients were placed on monotherapy at a median of 4.6 years post-HT [IQR 1.9-6.7 years]. Ten (83%) were transplanted as infants and 6 (50%) were transplanted for congenital heart disease. Nine (75%) were on tacrolimus monotherapy and 3 were on cyclosporine monotherapy. Indication for monotherapy was serious or chronic infection in 6 (50%), PTLD in 4 (33%), and neutropenia in 2 (16%). At a median follow-up of 1.5 years [IQR 1.1-2.2 years], 2 (16%) patients experienced grade 1B/1R cellular rejection, one of which required mechanical support and was transitioned back to dual therapy immunosuppression. All patients remain alive, with the remaining 11 (91%) still on monotherapy at time of last follow-up. Monotherapy immunosuppression with calcineurin inhibitors can be safely used in a subset of pediatric HT patients with evidence of over-immune suppression without significant increase in rejection. [ABSTRACT FROM AUTHOR]