Strategies for prolonged survival before heart transplantation in the neonatal intensive care unit.

From 1989 through 1992 we followed more than 200 fetuses and newborn infants referred for heart transplantation, of whom more than 140 were ultimately registered to receive a transplant. During this time, the interval before these infants underwent transplantation ranged from 1 day to 6 months. This experience left us with more questions than answers about the appropriate preoperative management of these patients. This article will focus on some of these areas of controversy. Our initial concern about the long-term management of these newborn infants was that ductal closure would be a major threat to their survival. However, our experience has proved otherwise. Although maintenance of ductal patency is a necessity for most neonatal transplantation candidates (83% have hypoplastic left-heart syndrome [HLHS] or one of its variants), the ductus has remained responsive to prostaglandin E1 (PGE1) infusion in most infants. For the rare infant whose ductus begins to close despite adequate PGE1 infusion, other innovative procedures (such as mechanical stenting of the ductus) have been devised and are currently under evaluation. Although ductal closure has not been a frequent occurrence in newborn infants awaiting heart transplantation, the variable shunting of blood through the ductus can cause significant and rapid changes in hemodynamics. This has prompted efforts to improve the balance between pulmonary and systemic vascular resistances by use of pharmacologic agents or by altering the mixture of inhaled gases. Attempts to decrease the PGE1 infusion and minimize exposure to other pulmonary vasodilators have been routine.(ABSTRACT TRUNCATED AT 250 WORDS)