Etiology and outcome of outpatient fevers in pediatric heart transplant patients.

We reviewed 74 outpatient febrile episodes in 22 pediatric heart transplant patients in order to determine etiologies, rates of serious and nonserious illness, and factors predictive of serious disease. Twenty-two febrile episodes (30%) resulted in hospital admission. Only three variables were predictive of serious illness: longer duration of fever, shorter time since transplant, and lower febrile episode number. We conclude that at least 70% of outpatient febrile episodes are nonserious and can be managed safely in an outpatient setting. The duration of fever may be predictive of serious disease but is not useful at initial presentation.

Epoetin alfa therapy in infants awaiting heart transplantation.

OBJECTIVE: To determine the safety and efficacy of epoetin alfa therapy in infants awaiting heart transplantation to minimize the need for blood transfusions. DESIGN: Prospective case series analysis. SETTING: Pediatric tertiary care center. PATIENTS: Eleven term infants (4 to 54 days old) awaiting heart transplantation. INTERVENTION: Infants received 16 courses of daily epoetin therapy and four subsequent courses of alternate-day epoetin therapy. RESULTS: Daily epoetin therapy was instituted at 23.6 +/- 4.5 days of age, and the duration of treatment was 13.8 +/- 3.9 days (mean +/- SEM). During daily epoetin therapy, the hematocrit increased from 0.42 +/- 0.015 to 0.50 +/- 0.019 (P < .001), and the reticulocyte count increased from 58 +/- 9 x 10(-3) to 105 +/- 16 X 10(-3) (P < .05). There were no significant changes in leukocyte count (13.4 +/- 1.0 X 10(9)/L vs 15.1 +/- 0.9 X 10(9)/L), platelet count (402 +/- 43 X 10(9)/L vs 387 +/- 39 X 10(9)/L), or creatinine (53 +/- 9 mumol/L [0.6 +/- 0.1 mg/dL] vs 53 +/- 9 mumol/L [0.6 +/- 0.1 mg/dL]) (not significant). Four patients received blood transfusions during daily epoetin therapy, but the amount of blood administered to patients was significantly less (0.9 +/- 0.5 mL/kg per day) than the phlebotomy losses (1.8 +/- 0.4 mL/kg per day) (P < .01). During alternate-day epoetin therapy, the hematocrit decreased from 0.53 +/- 0.014 to 0.43 +/- 0.019 (P < .05). CONCLUSIONS: Daily epoetin therapy appears to be effective in maintaining stable hematocrit in infants awaiting heart transplantation, who generally require multiple transfusions secondary to iatrogenic blood losses.

Methotrexate therapy in pediatric heart transplantation as treatment of recurrent mild to moderate acute cellular rejection.

We have used adjunctive therapy with methotrexate as treatment of recurrent mild-to-moderate acute cellular rejection and in an attempt to reduce rejection frequency and corticosteroid dosage. The purpose of this study was to review our experience with this treatment strategy. Eight patients, 13.1 +/- 1.1 years of age (mean +/- standard error of the mean) at the time of transplantation, were given methotrexate in addition to their standard triple therapy immunosuppression. Methotrexate was started at 6.2 +/- 2 months after transplantation after an average of 3.1 +/- 0.4 rejection episodes. Patients were given methotrexate weekly for 8 weeks at 2.5 or 5 mg orally every 12 hours for three doses (0.23 +/- 0.02 mg/kg/week). The time to resolution of rejection was 17.9 +/- 4 days after initiating methotrexate therapy. The number of rejections per month decreased significantly from the 2 months before methotrexate therapy (1.49 +/- 0.1) when compared with both the 2 months during methotrexate therapy (0.50 +/- 0.1) and the 2 months after methotrexate therapy was completed (0.44 +/- 0.3) (p < 0.005). Furthermore, when comparing total rejection frequency since transplantation and before methotrexate therapy to a follow-up period of 21.8 +/- 5 months after completion of methotrexate therapy, the rejection frequency was significantly less (0.81 +/- 0.2 versus 0.10 +/- 0.06 rejections/month) (p < 0.01). Prednisone dosage was also significantly less when comparing the time before methotrexate therapy to immediately after completion of methotrexate therapy (0.23 +/- 0.04 versus 0.15 +/- 0.03 mg/kg/day) (p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

The first pediatric Japanese case to undergo heart transplantation in the Utah Cardiac Transplant Program in the United States.

A seven-year-old girl underwent heart transplantation because of progressive congestive heart failure resulting from familial dilated cardiomyopathy. Her parents were second cousins to each other and her brother had died of dilated cardiomyopathy. Her symptoms of congestive heart failure began four months before the transplantation and became gradually worse. Left ventricular ejection fraction was 10 to 20% echocardiographically, and mitral and tricuspid valve regurgitation were present. Her condition of NYHA IV was not improved by treatment with dobutamine infusion and isosorbide dinitrate. She was transported to the Primary Children's Medical Center in Utah, USA, on July 22, 1991 in critical condition to undergo heart transplantation. Despite treatment with amrinone and additional catecholamines, she became semicomatose due to ischemic liver injury on July 24, 1991. A donor became available on July 25, 1991, and the transplantation was performed. Cardiac ischemic time was 97 min. Although she had transient OKT3 monoclonal antibody-related encephalopathy on her fifth postoperative day, she recovered normally. She had moderate rejection on the 20th postoperative day and mild rejection on the 79th and 149th postoperative days. She has had no significant infectious diseases. The baseline examination performed three months after heart transplantation revealed no abnormal findings on her coronary arteriogram. She returned to Japan and has been attending elementary school. The annual examination of her transplanted heart showed neither stenosis nor occlusion in her coronary angiogram. She has been receiving cyclosporine, azathioprine, and a low dose of prednisone as an immunosuppressive regimen. If she does not exhibit rejection, the use of steroids will be decreased or discontinued.

Murine monoclonal CD3 antibody (OKT3)-based early rejection prophylaxis in pediatric heart transplantation.

The purpose of this study was to review our experience with the use of OKT3 (a murine monoclonal CD3 antibody) used as immune prophylaxis for pediatric heart transplant recipients. Orthotopic heart transplantation was performed in 18 pediatric patients, 8 girls and 10 boys, ranging in age from 17 days to 17 years. OKT3 therapy was initiated intraoperatively at a dose of approximately 0.2 mg/kg and was administered at a dose of approximately 0.1 to 0.2 mg/kg/day for a period of 11.5 +/- 2.5 days. Daily average OKT3 levels were 1132 +/- 469 ng/ml. Side effects that occurred during OKT3 therapy were fever (59%), diarrhea (24%), headaches (24%), vomiting (18%), encephalopathy (12%), pulmonary edema (6%), and rash (6%). Infections occurred in 24% of patients, all within 6 months of transplantation. In the first year after transplantation, patients experienced 3.4 +/- 2.4 episodes of mild rejection and 1.0 +/- 0.8 episodes of moderate rejection. No patient experienced severe rejection. Five of the surviving 14 patients (36%) have been weaned from chronic steroid therapy, and 42% are being maintained on alternate-day prednisone at a dose of 0.06 +/- 0.02 mg/kg/day. Coronary artery disease developed in three patients; two of whom died. Actuarial survival was 83% at 1 year and 73% at 2 years. This report shows that OKT3 prophylaxis in pediatric heart transplantation can be used with acceptable short-term adverse side effects and overall survival.

Efficacy of 100 consecutive right ventricular endomyocardial biopsies in pediatric patients using the right internal jugular venous approach.

Indications for endomyocardial biopsy (EMB) in pediatric patients include cardiomyopathy and postheart transplant rejection surveillance. There have been few reports of the use of the internal jugular venous approach for right ventricular EMB in pediatric patients. In this study, we report our experience with 100 consecutive EMBs in pediatric patients using this approach. Indications for EMB were cardiomyopathy of unknown etiology in four patients, adriamycin cardiomyopathy in three patients, postheart transplant rejection surveillance in five patients, right ventricular outflow tract tumors in one patient, and sustained ventricular tachycardia in one patient. Histologic diagnoses of biopsy specimens included interstitial fibrosis, vasculopathy, hypertrophy, anthracycline cardiotoxicity, and various degrees of allograft rejection. All EMBs were performed successfully and without complications. We conclude that right ventricular EMB using the right internal jugular venous approach can be performed safely and successfully in pediatric patients as young as 2 months of age and repeatedly in patients as young as 8 years old.

Relaxation and imagery techniques without sedation during right ventricular endomyocardial biopsy in pediatric heart transplant patients.

Routine endomyocardial biopsies after heart transplantation can be performed in pediatric patients with the right internal jugular venous approach. To minimize hospital time, limit disruption of daily activities, and eliminate the need for sedation, biopsies in patients older than 7 years of age were done with relaxation and imagery techniques. No complications occurred with this method, and all patients tolerated the procedure well.