Current state of pediatric cardiac transplantation
Current state of pediatric cardiac transplantation
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DOI：
10.21037/acs.2018.01.07
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发表时间：
2018-01-01
影响因子：
3.1
通讯作者：
Dipchand, Anne I.
中科院分区：
文献类型：
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作者：
Dipchand, Anne I.
小儿心脏移植是终末期心力衰竭儿童的标准治疗方法。年龄范围的多样性、诊断的差异以及实践的变化，继续对循证实践和新技术的发展构成挑战。近期的治疗效果非常好，尤其是随着心室辅助装置（VADs）的更广泛应用。等待移植期间的死亡率仍然很高，了解等待移植期间和移植后的死亡风险因素有助于围绕移植候选资格和列入等待名单的时间做出决策。影响等待名单和总体生存率的最大差距仍然是婴儿和单心室生理患者的机械支持选择。尽管急性排斥反应逐渐减少，但抗体介导的排斥反应的诊断和管理变得越来越具有挑战性和复杂性，对移植前后检测到的抗HLA抗体的影响（包括何时以及如何干预）的理解能力也是如此。免疫抑制方案的趋势包括更多地使用诱导治疗以及避免使用类固醇或撤药方案。常见的长期并发症包括肾功能不全（可通过监测和肾脏保护策略缓解）和感染。功能预后良好，但在神经发育、不依从性以及从以儿童为中心的护理向以成人 为中心的护理过渡方面存在重大的社会心理挑战。心脏移植物血管病变（CAV）仍然是长期生存的障碍，尽管更明显的是，关于对移植物的影响对预后产生影响的客观证据是重要的。在小儿心脏移植受者中，再次移植很少见。小儿心脏移植不断发展，以应对儿童时期达到终末期心力衰竭的不同患者群体所面临的挑战。
Pediatric heart transplantation is standard of care for children with end-stage heart failure. The diverse age range, diagnoses, and practice variations continue to challenge the development of evidence-based practices and new technologies. Outcomes in the most recent era are excellent, especially with the more widespread use of ventricular assist devices (VADs). Waitlist mortality remains high and knowledge of risk factors for death while waiting and following transplantation contributes to decision-making around transplant candidacy and timing of listing. The biggest gap impacting both waitlist and overall survival remains mechanical support options for infants and patients with single ventricle physiology. Though acute rejection has decreased progressively, both diagnosis and management of antibody-mediated rejection has become increasingly challenging and complex, as has the ability to understand the implication of anti-HLA antibodies detected both pre- and post-transplantation-including when and how to intervene. Trends in immunosuppression protocols include more use of induction therapy and steroid avoidance or withdrawal protocols. Common long-term morbidities include renal insufficiency, which can be mitigated with surveillance and renal-sparing strategies, and infections. Functional outcomes are excellent, but significant psychosocial challenges exist in relation to neurodevelopment, non-adherence, and transition from child-centered to adult-centered care. Cardiac allograft vasculopathy (CAV) remains a barrier to long-term survival, though it is more apparent that objective evidence of an impact on the allograft is important with regards to impact on outcomes. Retransplantation is rare in pediatric heart transplant recipients. Pediatric heart transplantation continues to evolve in order to address the challenges of the diverse group of patients that reach end-stage heart failure during childhood.