MILESTONE: More Than 1,200 Children Bridged to Heart Transplantation with Mechanical Circulatory Support

Abstract

Pediatric mechanical circulatory support (MCS) has been successfully used to bridge numerous children to transplantation who otherwise would have been unlikely to survive on the waitlist and, in many cases, make them better transplant candidates. The purpose of this study was to analyze what the pediatric heart failure community has achieved over the last 15 years in reaching 1,200 cases of bridging children to heart transplantation. The United Network for Organ Sharing database was used to identify MCS patients ages 0–18 at the time of listing for heart transplantation between 2005 and 2019, divided into three eras: first (2005–2009), second (2010–2014), and third (2015–2019). From 2005 to 2019, 1,289 pediatric cases were identified. More patients were successfully bridged to transplantation with MCS in the third-era (28%) [vs. first-era (16%), second-era (24%), p ≤ 0.004]. The proportion of discharges on ventricular assist device has increased as well from 3% to 22% (p < 0.001). Post-transplant survival was significantly better in the third era (1-year survival: 96%; 3-year survival: 89%) compared to the two previous eras (p = 0.006). On MCS, renal dysfunction, ventilator dependence, inotrope use, and functional status improved from the time of listing to transplantation (p < 0.01). Hepatic dysfunction (p < 0.001), renal dysfunction (p = 0.004), congenital heart disease (p = 0.023), and infant age (p = 0.002) were risk factors for post-transplant mortality. Over the last 15 years, pediatric MCS has become an accepted and increasingly used strategy for bridging children to transplantation. MCS therapy is associated with improved end-organ function at the time of transplantation, perhaps contributing to the increasing post-transplantation survival of patients bridged with MCS.

Pulmonary Artery Banding for Dilated Cardiomyopathy in Children: Returning to the Bench from Bedside

“…A growing number of pediatric patients are nowadays bridged to HTX with MCS [ 6 , 7 ]. Guaranteeing adequate organ perfusion and LV unloading, the multiorgan function is optimized, and post-transplantation outcomes improve [ 7 , 8 ].…”

“…However, both these strategies are noncurative and turn the primary cardiac pathology into a chronic systemic disease. The immunosuppressive regimen and related risks of infection and malignancy represent the main concerns in pediatric HTX [ 9 , 10 ], as well as the hemorrhagic and thromboembolic morbidities in MCS [ 6 , 8 , 11 ]. Moreover, smaller patients can benefit from exclusively extracorporeal MCS devices (i.e., the Berlin Heart), which negatively affect the length of hospitalization, social costs, and quality of life [ 11 ].…”

Taking ACTION: A Prognostic Tool for Pediatric Ventricular Assist Device Mortality

“…1 Given the shortage of pediatric donors and the increased availability of ventricular assist devices (VAD), VAD implantation has become a widely accepted bridge to transplantation, and in the current era, approximately one-third of pediatric patients receiving a transplant are supported with VAD during the waitlist period. 2,3 In association with expanded VAD utilization, there has been a dramatic reduction in waitlist mortality by 50%. [4][5][6][7] Indications for VAD implantation in children have expanded to include the support of patients as a bridge to the decision, a bridge to recovery, and as destination therapy.…”

Single Center Experience With Durable Continuous Flow Single Ventricle Assist Device: A Viable Option in Fontan Circulatory Failure

“…5 Several centers have demonstrated feasibility of VAD therapy in patients with Fontan failure and with systolic dysfunction in individual case reports despite concerns regarding complex anatomy, prior sternotomies, and the frequency of end-organ dysfunction. 3,[6][7][8][9][10][11] Herein, we describe the use of continuous flow single ventricular assist devices (SVADs) in individuals with Fontan circulatory failure at a single children's hospital.…”