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Pediatric Transplantation Highlights from Prague

Melanie Everitt, Beth Kaufman, and Chris Benden
Pediatric Transplantation Council

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Prague, the "city of bridges," was the quintessential setting for symposia sessions that bridged interests of specialists in pediatric transplant, nursing, infectious disease, pulmonary hypertension, and cardiothoracic surgery.

Friday morning's symposium focusing on Fontan physiology highlighted the complicated decisions surrounding Fontan conversion, listing for heart transplant, and assessing need for concomitant liver transplant. It is clear that transplant specialists across the globe are charged with the care of these complex patients who are reaching adulthood in ever-growing numbers. We are only starting to see the tip of an iceberg with respect to cardiac cirrhosis and protein-losing enteropathy. Presently, there are more questions than answers related to the aging Fontan population. Even so, the symposium and related abstract sessions demonstrated that the transplant community is intent on seeking these answers and providing improved care through heart failure management and transplantation.

The Mechanical Circulatory Support in Pediatrics and Congenital Heart Disease Symposium provided key insights pertaining not only to the current state of devices but also to the prevention of device complications. Dr. Patricia Massicotte's (University of Alberta, Edmonton, Canada) discussion regarding thrombosis and anti-coagulation strategies was of particular importance as studies to date have reported significant stroke rates for children supported by ventricular assist devices. In short, anti-coagulation protocols are being constantly refined and will need to be further modified when new devices, new coagulation monitoring, and new medications come on the horizon. William Wrightson (Freeman Hospital, Newcastle, UK) spurred discussion regarding discharge to home for children with extracorporeal assist devices by providing insight into how this is done successfully in the U.K.

While the sun prevailed in Prague amid the forecasts of rain, "The Perfect Storm" of adolescents and adherence after organ transplantation was addressed in the symposium on Neurocognitive, Psychosocial and Behavioral Issues. The challenges of adolescent transplant care spilled over into the abstract sessions including Abstract 389 by Dr. Christina VanderPluym which demonstrated a steady increase in the rate of rejection through adolescence. This increased rejection rate appears to continue into young adulthood and is independent of age at listing.

For the pediatric lung transplant community, one of the focal points of the meeting was definitely the Friday Lunchtime Symposium on "Challenges in Pediatric Lung Transplant." Stuart Sweet (St Louis, MO), the 2012 Scientific Program Chair, reminded the audience that infants undergoing lung transplantation are "small but not forgotten". Based on the large experience of infant lung transplantation in St Louis, Dr Sweet reported on specific aspects of younger transplant recipients and their transplant outcomes. Even though infants often have a more difficult early post-op period, they are generally less affected by acute and chronic graft rejection and achieve similar survival rates to older children. However, somatic growth and development are more commonly impaired. Christian Benden (Sydney, Australia) reviewed issues and outcomes of re-transplantation in pediatric lung transplant recipients. Candidates ideally should not be mechanically ventilated prior to the re-transplant procedure and 1-2 yr after the primary transplant. Nevertheless, co-morbidities need to be evaluated vigilantly. If selected carefully, re-transplantation is a therapeutic option that can accomplish results similar to the primary transplant outcome. Charles Huddleston (St Louis, MO) spoke on the subject of "Bridging to Lung Transplantation in Children" and particularly on the use of pre- and post-op ECMO support. ECMO use in children is associated with a significant morbidity and mortality. The use of other interventional lung assist devices in pediatric lung transplant candidates is still limited. Finally, Joseph Pilewski, an Adult Chest Physician from Pittsburgh, PA, gave a fascinating talk on transition from pediatric to adult care. It is clear that transition should be of interest for both pediatric and adult transplant teams. We should promote patient-centered and age-adjusted healthcare to overcome potential hurdles to successful transition.

Other highlights of the meeting for both Pediatric and Adult Pulmonologists included a symposium on the "Evolving concepts of chronic lung allograft dysfunction" where definitions, different phenotypes, emerging pathways and future therapies were discussed by an expert panel of speakers from both sides of the Atlantic and across the Pacific to down under. A symposium on viruses in thoracic transplantation attracted a large crowd of delegates. Topics such as EBV infection and PTLD, and respiratory viruses were of particular interest for Pediatric Pulmonologists. Further hot topics of the meeting were reviews of lung transplantation for pulmonary hypertension and special considerations for CF patients undergoing lung transplantation that culminated in energetic discussions.

The ISHLT 2012 Annual Meeting and Scientific Sessions will be remembered for great science, stimulating discussions, and the vibrant city skyline, but especially for ISHLT's collegial atmosphere that is the key to the advancement of pediatric thoracic transplantation.

Disclosure Statement: The authors have no conflicts of interest to disclose.