Acute graft rejection in pediatric heart transplant patients is a cause of significant mortality. A retrospective review of the heart transplant database at our institution from 6/96 until 2/07 was conducted with IRB approval. All patients who required inotropic support during an episode of acute graft rejection were identified and included for analysis. The incidence of transplant coronary artery disease (TCAD) before and after hemodynamically significant rejection was examined.
Fifty-three patients had 70 rejection episodes requiring intravenous inotropic support. Low dose support, defined as ≤2 inotropes [milrinone (≤0.5mcg/kg/min), dopamine or dobutamine at <10mcg/kg/min] was required in 32 patients. Survival to hospital discharge was 41% in the high dose group (HDG) compared to 94% in the low dose group (LDG). There was no difference in graft age or survival to discharge for those with and without TCAD at presentation with acute rejection. At 6 months, no additional patients in the HDG died compared to continued graft loss (47% graft survival) in the LDG.
Of the 9 patients in the LDG who died suddenly at home, 8 had documented TCAD. New TCAD developed in 5, while 2 had stable TCAD and 1 had progression of TCAD since the rejection episode. In contrast, only one patient in the HDG developed new TCAD or had progression of disease following treatment for rejection. Patients with TCAD have a high late mortality risk following an episode of hemodynamically significant rejection even if only low dose inotropes are required.