Developing a Virtual Heart Library for Use in Pediatric Heart Transplant Allograft Size Selection

Introduction: There are 350 to 400 pediatric heart transplants annually according to the Pediatric Heart Transplant Database (Dipchand et al. 2014). Finding appropriate donors can be challenging especially for the pediatric population. The current standard of care is a donor-to-recipient weight ratio. This ratio is not necessarily a parameter directly indicative of the size of a heart, potentially leading to ill-fitting allografts (Tang et al. 2010). In this paper, a regression model is presented - developed by correlating total cardiac volume to non-invasive imaging parameters and patient characteristics – for use in determining ideal allograft fit with respect to total cardiac volume.
Methods: A virtual, 3D library of clinically-defined normal hearts was compiled from reconstructed CT and MR scans. Non-invasive imaging parameters and patient characteristics were collected and subjected to backward elimination linear regression to define a model relating patient parameters to the total cardiac volume. This regression model was then used to retrospectively accept or reject an ‘ideal’ donor graft from the library for 3 patients that had undergone heart transplantation. Oversized and undersized grafts were also transplanted to qualitatively analyze virtual transplantation specificity.
Results: The backward elimination approach of the data for the 20 patients rejected the factors of BMI, BSA, sex and both end-systolic and end-diastolic left ventricular measurements from echocardiography. Height and weight were included in the linear regression model yielding an adjusted R-squared of 82.5%. Height and weight showed statistical significance with p-values of 0.005 and 0.02 respectively. The final equation for the linear regression model was TCV = -169.320+ 2.874h + 3.578w ± 73 (h=height, w=weight, TCV= total cardiac volume).
Discussion: With the current regression model, height and weight significantly correlate to total cardiac volume. This regression model and virtual normal heart library provide for the possibility of virtual transplant and size-matching for transplantation. The study and regression model is, however, limited due to a small sample size. Additionally, the lack of volumetric resolution from the MR datasets is a potentially limiting factor. Despite these limitations the virtual library has the potential to be a critical tool for clinical care that will continue to grow as normal hearts are added to the virtual library.