The Impact of the Number of Prior Sternotomies on Survival and Complications Following Pediatric Heart Transplantation

Background The impact of prior sternotomies on pediatric heart transplant outcomes remains unclear. Given the increasing prevalence of reoperative candidates, clarifying this relationship is important for contemporary risk stratification. Methods We retrospectively analyzed 3253 pediatric heart transplant recipients in the Organ Procurement and Transplantation Network database. Pediatric heart transplant records from 1987 to 2025 were screened, and the analytic cohort was restricted to eligible primary transplants performed from 2002 to 2025. Patients were categorized as having no prior sternotomy (NS, n = 110), 1 to 2 prior sternotomies (1-2S, n = 2315), or ≥3 prior sternotomies (≥3S, n = 828), using clinically meaningful groupings supported by exploratory spline analysis. Results Recipients with ≥3 prior sternotomies were older, more often had congenital heart disease, and had higher body mass index, serum creatinine, and bilirubin, longer waitlist duration, and longer ischemic time. Pretransplant mechanical ventilation was less frequent in the ≥3S group. Posttransplant dialysis was more frequent in ≥3S than in 1 to 2S recipients, while treated acute rejection was more frequent in ≥3S than in both other groups. Stroke and permanent pacemaker implantation did not differ across groups. Survival at 30 days, 90 days, 1 year, and 5 years was lower in ≥3S than in 1 to 2S recipients; comparisons involving the smaller NS group were not statistically significant. In a prognostic multivariable logistic model incorporating recipient, transplant, and posttransplant factors, prior sternotomy burden was not independently associated with all-cause mortality at the most recent follow-up. Conclusion The number of prior sternotomies was associated with increased morbidity but was not independently associated with mortality in the prognostic multivariable model.