(638) Transfusion-Free Fontan Heart Transplants are Achievable: Initial Experience

PurposePerioperative bleeding is a high source of morbidity and mortality for patients undergoing a heart transplant (HT) for Fontan failure (FF), due to multiple sternotomies, collaterals, and the potential for coagulopathy related to Fontan-associated liver disease (FALD) and warfarin use. We sought to determine whether our institution's transfusion reduction program could lead to a successful bloodless HT for FF.MethodsRetrospective review of all patients who underwent HT for FF at a single institution, following the implementation of a blood conservation program (5/2021-10/2022). Patients were considered to have received a peri-HT blood product if they received a transfusion of packed red blood cells, cryoprecipitate, platelets, or plasma in the operating room or during the entire post-HT hospitalization.ResultsNine FF patients underwent HT at a median age of 13.8 (IQR 13.1,15.2) years; the oldest patient was 20.9 years. Patients were listed pediatric 1B (n=5), 1A (n=3) or Adult Status 4 (n=1) at the time of transplant and had been waiting a median of 54.5 (10.5,120.8) days. Most patients had evidence of advanced FALD on liver biopsy (n=7) and/or CTA abdomen (n=7); only 1 patient did not have either study. Six patients were anticoagulated with warfarin prior to HT and received Vitamin K reversal prior to HT. Three (33%) patients did not require any blood products peri-HT; of note, all 3 had Stage 3 liver fibrosis by biopsy and had a higher GGT (p=0.01) compared to those patients who did require a transfusion (Table). There was one infectious mortality in this series at POD52 in a patient with protein losing enteropathy; this was the only patient who required post-HT dialysis.ConclusionWhile the small number of patients precludes robust conclusions, it is possible to perform bloodless HTs for Fontan patients even in the setting of known risk factors for bleeding, including FALD, pre-HT milrinone use, and warfarin use. Given the high prevalence of sensitization in congenital patients, it may be worth attempting bloodless HTs. Perioperative bleeding is a high source of morbidity and mortality for patients undergoing a heart transplant (HT) for Fontan failure (FF), due to multiple sternotomies, collaterals, and the potential for coagulopathy related to Fontan-associated liver disease (FALD) and warfarin use. We sought to determine whether our institution's transfusion reduction program could lead to a successful bloodless HT for FF. Retrospective review of all patients who underwent HT for FF at a single institution, following the implementation of a blood conservation program (5/2021-10/2022). Patients were considered to have received a peri-HT blood product if they received a transfusion of packed red blood cells, cryoprecipitate, platelets, or plasma in the operating room or during the entire post-HT hospitalization. Nine FF patients underwent HT at a median age of 13.8 (IQR 13.1,15.2) years; the oldest patient was 20.9 years. Patients were listed pediatric 1B (n=5), 1A (n=3) or Adult Status 4 (n=1) at the time of transplant and had been waiting a median of 54.5 (10.5,120.8) days. Most patients had evidence of advanced FALD on liver biopsy (n=7) and/or CTA abdomen (n=7); only 1 patient did not have either study. Six patients were anticoagulated with warfarin prior to HT and received Vitamin K reversal prior to HT. Three (33%) patients did not require any blood products peri-HT; of note, all 3 had Stage 3 liver fibrosis by biopsy and had a higher GGT (p=0.01) compared to those patients who did require a transfusion (Table). There was one infectious mortality in this series at POD52 in a patient with protein losing enteropathy; this was the only patient who required post-HT dialysis. While the small number of patients precludes robust conclusions, it is possible to perform bloodless HTs for Fontan patients even in the setting of known risk factors for bleeding, including FALD, pre-HT milrinone use, and warfarin use. Given the high prevalence of sensitization in congenital patients, it may be worth attempting bloodless HTs.