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Pediatric heart transplant waitlist mortality remains significant but allograft offer refusals are common and allografts continue to be discarded. Our aim in this study was to assess the impact of donor organ refusals on mortality after listing using a multi-institutional data set.In this study we conducted a retrospective review of donor offers made to pediatric (18 years) recipients in the United States in the period from 2007 to 2017. Candidates were stratified by whether they refused an acceptable donor offer (ADO). Acceptance was defined as an offer from a donor40 years old and within 1,000 miles that was ultimately accepted by a waitlist candidate. Candidate survival after an offer was assessed.There were 12,447 hearts offered at least once to a pediatric candidate. Most candidates (n = 4,282, 84.4%) refused the first offer, and 677 (15.4%) of these subsequently died or were removed from the list for deterioration. Refusal of an ADO was associated with higher mortality after listing, independent of transplant, in both univariate (1 year: 92% vs 87%, p = 0.002) and multivariate (hazard ratio 1.5, 95% CI 1.2 to 1.7, p0.0001) Cox regression analyses. ADO refusals were not correlated with improved post-transplant survival and8 ADO refusals was associated with higher risk-adjusted post-transplant mortality (odds ratio 1.7, 95% confidence interval 1.0 to 2.9, p = 0.04).Refusal of ADOs is associated with higher risk-adjusted mortality after listing (independent of transplantation), without improvement in post-transplant outcomes. So, although a "perfect" organ would be ideal, acceptance of one that is "good enough" has the potential to improve survival among pediatric candidates for heart transplantation.

Introduction: Recent studies have suggested a relationship between mortality and center volume in pediatric heart transplantation; however, these studies utilize databases that lack granularity to assess patient risk profiles. Hypothesis: Utilizing the Pediatric Heart Transplant Society (PHTS) database, we hypothesized that there would be a difference in outcomes among centers based on yearly transplant volume, and that the patient’s clinical profiles would differ by center volume. Methods: We performed a retrospective analysis of the PHTS dataset from all pediatric (≤ 18 years of age) cases from 2009-2018. Centers were stratified into 5 groups based on annual volume: ≤ 4, 4-6, 6-9, 9-14, and > 14 transplants. We evaluated specific variables, including those identified as significant risk factors in previous PHTS studies including mechanical ventilation, PRA > 10%, high BUN, gender, and Fontan completion, within each group. We used Kaplan Meier for survival, contingency tables with Pearson Chi-square test for association, and analysis-of-variance to compare means. P< 0.05 was considered statistically significant. Results: There were 6800 cases among 55 centers. Table 1 demonstrates that there was no significant difference in one-year post transplant survival among the groups, and the patient variables showing statistically significant differences followed no specific pattern among the center volume groups. It also demonstrates that there is no clear association between cumulative risk factors within individual patients and center volume. Conclusions: One-year post transplant survival is similar within the PHTS for all centers regardless of case volume. These group differences were different for different variables and did not segregate consistently between lower volume and higher volume groups suggesting there exists a complicated relationship among risk factors and center volume.

BACKGROUND Pediatric donor heart acceptability differs among transplant centers. However, the impact of center donor acceptance on waitlist and posttransplant outcomes has not been investigated. The aim of our study was to investigate associations between transplant center refusal rate (RR) and outcomes after listing. METHODS Retrospective analysis was performed using United Network for Organ Sharing/Organ Procurement and Transplant Network pediatric (

Significant inter- and intra-center practice variability is present in pediatric donor heart acceptability. This may contribute to variation in the donor refusal rate and may impact waitlist time, morbidity, mortality, and transplant rates. In order to reduce practice variability, our center developed and implemented a comprehensive strategy regarding donor acceptance in September 2017. The aim of this study was to assess the impact of this strategy on waitlist time and outcomes as well as early post-transplant outcomes. We performed a single-center, retrospective analysis of all pediatric (18 years) patients listed for single-organ heart transplant at our center from September 2015 to September 2018. Patients were divided into those listed before (Group 1) and after implementation of the comprehensive strategy (Group 2). The primary end-point was waitlist time. Secondary end-points included waitlist removal due to death or clinical deterioration, donor refusals per listed patient, early post-transplant outcomes (graft failure, mechanical ventilation time, inotropic support, length of hospital stay) and 1-year post-transplant survival. Of 78 listed patients, 54 were transplanted (29 in Group 1), 9 were removed due to death or clinical deterioration (7 in Group 1) and 15 were removed due to clinical improvement (12 in Group 1). The waitlist time was significantly shorter in Group 2 (17 days, IQR 7-53) vs Group 1 (90 days, IQR 14-162); P = .006. The number of donor refusals was lower in Group 2 (1, IQR 0-2.2) vs Group 1 (4, IQR 2-19); P .001. The percentage of refused donors with normal function (Left ventricular ejection fraction 50%) was lower in Group 2 vs Group 1 (53% vs 84%; P .001). Difference in removal from the waitlist for death or deterioration in Group 2 vs Group 1 (n = 2, 7% vs n = 7, 20%, P = .18) did not reach statistical significance. There was no difference in post-transplant outcomes between groups. The waitlist time and donor refusals significantly decreased after implementation of a comprehensive donor acceptance strategy without impacting transplant outcomes. This analysis supports the need for a comprehensive approach to donor organ acceptance within a pediatric transplant center.

Ischemic cardiomyopathy with resultant refractory HF may occur in patients with WBS, often as the result of coronary involvement with SVAS. The rapid development of arteriopathy at a young age raises concerns regarding transplant candidacy due to progressive stenoses at other arterial sites with potential detrimental impact on long-term heart graft function. We report a 2-month-old male infant diagnosed with mild aortic stenosis during the neonatal period, but subsequently developed rapidly progressive supravalvar and coronary artery stenoses leading to cardiogenic shock due to myocardial ischemia. The presentation led to the diagnosis of WBS. He required prolonged CPR including ECMO therapy. He subsequently underwent LVAD implantation as bridge to transplant and 4 days later heart transplantation. His post-operative course was complicated by prolonged mechanical ventilation and extended intensive care unit and hospital stays. However, at follow-up 18 months post-transplant he continues to have normal graft function with mild, non-progressive residual coarctation of aorta and non-progressive moderately hypoplastic pulmonary arteries.

Purpose Mental health disorders have deleterious effects on outcomes in adult heart failure. Mental health is not systematically investigated or screened in pediatric heart failure and transplantation patients. Methods Our institution implemented universal mental health screening for all patients age 11 or older in our pediatric heart failure and transplant clinic. 17 items are answered on a tablet while the patient awaits cardiac testing. Validated mental health screening tools are utilized: the Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder scale (GAD-7). Scores for both scales range from 0-4 = no symptoms, 5-9 = mild symptoms, 10-14 = moderate symptoms, > 15 = severe symptoms. Scores are immediately available in the electronic health record. The presence of suicidal ideation, severe depression and/or anxiety leads to notification of the psychologist for further intervention. Results 94 patients have been screened to date. Median age was 16.25 years (IQR 14.7-18.4). Median PHQ-9 score was 2 (IQR 0-6) and 2 (IQR 0-5.3) for GAD-7. Four patients (4.3%) reported severe depression, 8 (8.5%) moderate depression, 15 (16%) mild, 67 (71.3%) reported no depressive symptoms. Seven patients reported suicidal ideation (7.5%). Six patients (6.4%) reported severe anxiety, 8 (8.5%) moderate anxiety, 14 (14.9%) mild anxiety and 66 (70.2%) reported no anxiety. There were no differences in mental health scores between heart failure and transplant patients (Table 1). Eighteen new behavioral health interventions were implemented due to screening. Conclusion Electronic mental health screening can successfully be employed in pediatric heart failure and transplant clinics. A significant portion have moderate to severe anxiety (14.9%) or moderate to severe depression (12.8%). Mental health screening has led to many behavioral health interventions in this population. Our initial experience supports the use of mental health screening in a pediatric heart failure and transplant clinic.

This study aims to compare 2 common induction strategies, basiliximab and ATG. Analysis of the ISHLT transplant registry was performed. The database was queried for pediatric heart transplants from January 1, 2000, to June 30, 2015, who had received induction with basiliximab or ATG. Primary end-point was graft survival. Secondary end-points included 1-year survival and 1-year conditional survival. There were 3158 heart transplants who received induction with basiliximab or ATG. The ATG cohort was younger, more likely to have congenital heart disease or be a retransplant, have a higher PRA, longer ischemic time, and been transplanted earlier in the study period (all P

Purpose Geographic variation in donation rates, transplant rates, and post-transplant outcomes in solid organ transplantation is well-described. We sought to test the hypothesis that organ refusal rates vary across regions and are associated with worse survival. Methods Retrospective review of the UNOS dataset (including the potential transplant recipients list which lists all offers of organs ultimately accepted for transplant) identified 5,639 pediatric ( heart transplant 2007-2017. Patients were stratified based on the UNOS region of listing. There were 12,447 donor hearts ( Results Regional refusal rates varied:73.5% to 93.1% (Table). Higher rates correlated with a lower likelihood of transplantation (r=0.60, p=0.048), higher waitlist mortality (r=0.67,p=0.008), a higher incidence of delisting for death or deterioration (r=0.61, p=0.04), higher mortality within 1 year of listing independent of transplant (r=0.080, p=0.003; see Figure), and higher 1 year post-transplant mortality (r=0.82, 0.002). Regional refusal rates were not correlated with mean regional wait times, or the number of donors available for each listed candidate. Conclusion Donor refusals rates vary widely between UNOS regions. Regions with high refusal rates also have poor outcomes following listing and transplantation.

Purpose Approximately 40% of potential pediatric heart donations go unused, while waitlist mortality remains high. The aim of our study was to investigate associations between center refusal rate and waitlist outcomes. Methods Retrospective analysis was performed using UNOS/OPTN pediatric ( Results 5,639 listed patients in 59 centers met inclusion criteria. The lowest quartile of center had a median RR of 75th percentile had a RR ≥ 4. There was no association between RR quartile and transplant center volume (p=0.4). Centers in the highest RR quartile were more likely to remove patients from the waitlist due to death or clinical deterioration versus those at lowest RR quartile (24.1% vs 14.6%, p Conclusion Patients listed at high RR centers had worse survival from listing. High RR centers are more likely to remove patients from the waitlist due to death or clinical deterioration and are less likely to transplant patients. Refusal rate is not associated with center transplant volume.

Purpose Lack of standardization in organ donation acceptance can contribute to an increased donor refusal rate, which may impact waitlist (WL) time, morbidity, mortality and transplant rates. After a review of relevant data, in 9/2017, our center developed and implemented a standardized donor acceptance criteria. We hypothesized that standardization would result in a decrease in WL time and improved WL outcomes. Methods We performed a single center, retrospective analysis of all pediatric ( Results Of 78 listed, 54 were transplanted, 8 removed due to death/clinical deterioration, 16 removed to due clinical improvement. Patient characteristics were similar between the groups (Table 1). Difference in removal from the WL for death or deterioration in Group 2 vs. 1 (n=2, 7% vs. n=6, 17%, p=0.28) did not reach statistical significance. WL time was significantly shorter in Group 2 (17 days, IQR 6-55) vs. Group 1 (90, IQR 13-167; p=0.006). The median DOR was lower in Group 2 (2, IQR 0-3) vs. Group 1 (4, IQR 2-20; p=0.001). The percentage of DOR with LVEF > 55% was lower in Group 2 vs. Group 1 (53% vs. 84%, p=0.001). Post-transplant outcomes were similar between groups (table 1). Conclusion DOR and WL time significantly decreased after a standardized donor acceptance criteria. This analysis supports the need for a standardized approach to donor organ acceptance within a pediatric transplant center.