Andersons pediatric cardiology 1783

FIG 67.15 Percentage of patients bridged with mechanical circulatory support to heart transplantation ECMO, Extracorporeal membrane oxygenation; LVAD, left ventricular assist device; RVAD, right ventricular assist device; TAH, total artificial heart; VAD, ventricular assist device (From the registry of the International Society of Heart and Lung Transplantation J Heart Lung Transplant 2016;35(10):1185–1195.) FIG 67.16 Percentage of patients bridged with mechanical circulatory support to heart transplantation stratified by age group ECMO, Extracorporeal membrane oxygenation; LVAD, left ventricular assist devices; RVAD, right ventricular assist device; TAH, total artificial heart; VAD, ventricular assist device (From the registry of the International Society of Heart and Lung Transplantation J Heart Lung Transplant 2016;35(10):1185–1195.) Management of the Donor and Recipient Considerations Relative to the Donor The mechanism of death, resuscitation, and the type of support required have a significant bearing on the suitability of an organ for transplantation There is accumulating knowledge on the effect of brain death on cardiac function and the best methods to support the circulation to preserve cardiac function for subsequent donation The response to acute traumatic brain death can be a profound decrease in ventricular function, with the myocardium of the right ventricle more affected than that of the left.41 When compared to pediatric donors without cardiac dysfunction, the proportion of procured hearts was significantly lower in those with cardiac dysfunction (56% vs 84%).42 With appropriate “donor management” and time, greater than 50% of donors with global left ventricular dysfunction and/or regional wall motion abnormalities have been shown to improve enough to allow for organ procurement, as high as 82% in the one pediatric study.42 Given the donor:recipient imbalance and the reality of waitlist mortality, it is important to explore donor organ utilization and optimize all possible factors to maximize donor organ availability Therapy should be directed toward the restoration of intravascular volume and appropriate support of the myocardium and vascular system to ensure optimal cardiac output Detailed discussion regarding the optimal management of the organ donor is published elsewhere,43 but serial echocardiography is essential to reassess suitability for donation.42 Much emphasis has been placed on the development of better cardioplegia and preservation solutions as well as optimizing temperature during transport of the harvested donor heart in order to mitigate the effect of ischemia reperfusion on the myocardium.44 Donor ischemic time, a known risk factor in the adult population, remains controversial in children, with some studies suggesting that it may be a risk factor for primary graft dysfunction.45–47 However, in a more recent analysis of the PHTS registry, ischemic time did not have an impact on overall recipient survival, although longer ischemic times negatively impacted 1year posttransplant survival Analyzed by recipient age, longer ischemic time and a greater age difference between the recipient and donor impacted earlyphase survival for recipients who received a transplant at greater than 10 years of ... profound decrease in ventricular function, with the myocardium of the right ventricle more affected than that of the left.41 When compared to pediatric donors without cardiac dysfunction, the proportion of procured hearts was significantly lower in those with cardiac dysfunction (56% vs... global left ventricular dysfunction and/or regional wall motion abnormalities have been shown to improve enough to allow for organ procurement, as high as 82% in the one pediatric study.42 Given the donor:recipient imbalance and the reality of waitlist mortality, it is important to explore donor organ utilization and