Early school-age cognitive performance post-pediatric heart transplantation

Gold A, Bondi BC, Ashkanase J, Dipchand AI.Pediatr Transplant. 2020 Dec;24(8):e13832. doi: 10.1111/petr.13832. Epub 2020 Oct 26.PMID: 33105067

Take Home Points

• In this small (n= 25), but well controlled study of post-transplant pediatric patients, intellectual, academic, and perceptual-motor domain scores were low average while memory abilities were average.
• Clinical DSM-5 psychological diagnosis was present in >50% of the patients studied.
• Presence of a congenital heart disease and/or psychological diagnosis predicted worse neuropsychological domain scores.
• Close neuropsychological monitoring of these patients are needed to maximize long-term outcomes.

Commentary from Dr. Clifford Cua (Columbus Ohio USA), section editor of Pediatric/Fetal Cardiology Journal Watch: Previous literature, using heterogeneous methodologies, has documented increased developmental delay, neuropsychological deficits in cognition, and decreased academic achievement in pediatric heart transplant patients with an incidence ranging from 10 – 50%. The goal of this study was to evaluate a non-biased patient sample under uniform conditions and time intervals to better understand the neuropsychological outcomes in these patients.

Patients who underwent cardiac transplantation < 2 years of age were recruited. Multiple neuropsychological assessment tools (Table 1) were performed till entry into grade school. Scores were designated average (90 – 109), low average (80 – 89), well below average (70 – 79), and significantly poorer than age expectations (< 70). The study was performed from January 2014 to October 2018. Patients were excluded if they had been assessed before or could not follow up for testing. Baseline demographics as well as clinical data were recorded.

Thirty-one patients underwent transplantation during the study period and 25 qualified for the study (18 females, 7 males). Median age at transplantation was 0.71 years and age at testing was 6.7 years. Fourteen patients had CHD and 11 had cardiomyopathy. 72% had neurological issues and 68% had sensory issues pre- or post-transplant.

General intellect, academic, and perceptual motor indices were in the low normal range, whereas memory indices were in the normal range (Figure 1 – 3). Fourteen (56%) patients met DSM-5 criteria for a clinical diagnosis (intellectual disability mild 20%, learning disability 20%, language disorder 8%, and ADHD 12%). Another 8 (32%) patients were deemed at risk for developing issues.

There was a negative correlation between prior neurological issues (stroke, seizure, microcephaly, or other) and full-scale intelligent quotient, verbal comprehension, working memory, visual learning, verbal story learning, and short delay verbal story memory. There was a negative correlation with CHD and full-scale intelligent quotient, working memory, and fluid reasoning.

This study reinforces the need to closely follow up these patients from a neuropsychological standpoint so that early intervention can be performed to maximize long-term outcomes. Though not surprising, it also reinforces that patients with a congenital heart disease diagnosis or prior neurological issues are at increased risk for poorer neuropsychological outcomes. Though the study was small, from a single institution, and had a limited follow up time period, it has the benefits of being complete in its assessment of the patient population.