Orthotopic heart transplantation for failing single ventricle physiology

Objective: Evaluation of incremental risk factors for early mortality in children undergoing orthotopic heart transplantation (OHT) for failing single ventricle physiology. Methods: Between 1988 and 2002, 25 patients (mean age 9.3 +/- 7.1 years) underwent OHT for complex congenital heart disease (CHD) with a functional right ( 15 patients) or left ( 10 patients) single ventricle. Palliative staging towards Fontan completion had been previously accomplished in 22 patients (88%). Transition to OHT occurred from a shunt stage in 10, a bi-directional cavopulmonary anastomosis (BDG) stage in nine, and after Fontan failure in six patients. Results: Thirty-day survival was 68.0 +/- 9.3% with no additional mortality up to 14.1 years. OHT following BDG staging exhibited 100% long-term survival, as opposed to 66.7 +/- 15.7% for OHT after systemic-to-pulmonary shunt, and 33.3 +/- 19.2% for OHT following failing Fontan (p = 0.032). Regression logistic modelling indicated failing Fontan circulation as predictor of higher mortality after OHT (p = 0.041). Reintervention was necessary in four patients 40 +/- 11 months after OHT to address residual Superior vena cava (two) and isthmic (two) stenosis. Overall freedom front reintervention was 88.3 +/- 8.1 % at 5 years. Conclusions: OHT for structural CHD with single ventricle physiology entails substantial early mortality while BDG enables the best transition to heart transplant. OHT should be considered in the decision-making process as ail alternative to Fontan completion in high-risk candidates, since rescue-OHT after failing Fontan seems unwarranted. (C) 2003 Elsevier B.V. All rights reserved.