Cerebrovascular events in children on intracorporeal continuous‐flow left ventricular assist devices

Abstract

Continuous-flow intracorporeal left ventricular assist devices (CF-LVAD) are used more frequently in the pediatric population. One of the major complications of CF-LVAD is cerebrovascular events (CVEs). Limited information is available on this complication in pediatric patients. We hereby present our experience on CVEs in children under CF-LVAD support in our institution. A retrospective, single center review of 21 patients younger than 19 years of age who underwent CF-LVAD implantation between June 2014 and September 2018 was performed. Patients on biventricular support and extracorporeal devices were excluded. Cerebrovascular accidents (CVAs)-ischemic or hemorrhagic-were investigated. CVE was confirmed by brain computed tomographic scan. Of 21 pediatric patients, 11 were male. Mean BSA was 1.05 ± 0.41 m 2 and mean age was 11.05 ± 4.07 years. Dilated cardiomyopathy was the leading cause of heart failure. The patients were implanted with HeartWare hVAD (n = 19), HeartMate II (n = 1), and HeartMate 3 (n = 1). Mean support time was 421 ± 448 (18-1460) days. Target international normalized ratio was between 2.5 and 3.0. Nine (43%) patients underwent transplantation, one patient recovered with subsequent device explantation. Four (17%) patients were still on support. One patient (5%) died in the early postoperative period and six (28%) patients died on VAD support after a mean duration of 194 days. There were overall five cerebral hemorrhagic strokes in four patients (0.2 events per patient-year). CVA occurred between 250 and 1320 days (mean 600 days). No ischemic stroke was documented. Only one (20%) patient died after hemorrhagic stroke; the other three patients recovered and were discharged from the hospital with minor sequelae. Incidence of CVE in children on CF-LVAD is relatively low compared with adults on VAD and severity of stroke is milder than adult population.

Pediatric ventricular assist device registries: update and perspectives in the era of miniaturized continuous-flow pumps

“…Finally, pump thrombosis can lead to morbidity in the form of stroke. One study found that 50% of patients who suffered from an ischemic or hemorrhagic stroke had been treated for pump thrombosis previously (29). This finding was also noted in another study of stroke rates in CF-VADs, with 75% of patients suffering a CVA having been previously treated for pump thrombosis (10).…”

“…CVAs are one of the most significant complications following long-term CF-VAD implant, with the majority of events occurring early after implant (29). Single center analyses have shown that CVA rates vary between centers.…”

Myocardial recovery in children supported with a durable ventricular assist device—a systematic review

“…Some of our included studies seem to reflect this too. For example, some studies with older patients show lower recovery rates [ 15 , 16 , 21 , 25 ], whereas others with younger children show higher recovery rates [ 22 , 35 ].…”

Advances in Extracorporeal Support Technologies in Critically Ill Children

“…The HeartWare HVAD was removed from the market in June 2021, due to an the rates of thromboembolic stroke seen in adult patients supported with the device. Although this was not evident in pediatric patients, the device is no longer available for any population [ 49 ]. As a result, the choice of implantable devices for even larger children and teenagers is again somewhat limited.…”