Assessing the Relationship Between Pediatric Donors' Terminal Hospitalizations and Heart Acceptance Practices

Purpose

Prior studies suggest half of all donor hearts offered to pediatric waitlisted patients are declined despite a nearly 20% waitlist mortality. We evaluated the association between a pediatric heart donor's terminal hospital course and pediatric recipient acceptance practices.

Methods

Retrospective UNOS database study of all pediatric (<18 years) donors offered to pediatric patients from 1/1/2010 to 12/31/2020, including the PDF versions of all echocardiogram (echo) results performed during the terminal hospital course.

Results

5836 hearts were offered 34,078 times with a median initial offer occurring 8.9 (IQR 0.0, 13.4) hours post brain death (BD). Overall acceptance was 62.6%, though acceptance rates varied significantly by age, as seen in Table 1. Highest troponin values, vasoactive infusion (VIS) and PELD scores were significantly higher in rejected hearts. Thyroid repletion was uncommon but occurred significantly more often in rejected donors (8.8% (95% CI 4%, 13.6%) vs 6.8% (95% CI 3%, 10.5%), respectively, p=0.021). 5% of all donors did not have a documented echo, 62.4% had one, 25.3% had two and 7.1% had ≥3. Median time to first post BD echo was 15.7 (IQR 7.5, 21.9) hours at which time ≥50% of all rejected pediatric donor hearts demonstrated normal left ventricular (LV) function; right ventricular (RV) dysfunction occurred in less than 10% of all echos. Pre BD echos (median 36.4 (IQR 78.3, 11) hours pre BD) were much less common but exhibited more evidence of LV dysfunction.

Conclusion

Pediatric donor characteristics and management practices differed between groups and may have affected acceptance practices. Although approximately 1/3 of the Pre BD echoes on rejected donors showed moderate to severely depressed LV function, more than half of Post BD echoes on rejected donors demonstrated normal biventricular function. Assessment of the effects of hemodynamic status and current vs prior echo data on both acceptance practices and recipient outcomes is warranted and underway.