The importance of mechanical circulatory support on pediatric waitlist and post heart transplant survival: a narrative review

Bearl, David W.

doi:10.21037/pm-21-10

Cited by 4 publications

(2 citation statements)

References 43 publications

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“…Following their introduction in adults with cardiac compromise, MCS devices-such as the VAD-began to play an integral role in the management of pediatric heart failure in the 1990s (3). Given that the demand for pediatric donor hearts continues to outpace supply, these devices have become increasingly utilized as a bridge to cardiac transplantation over the past several years and have been effective in reducing waitlist mortality (1,4).…”

Section: Mechanical Circulatory Support: a Changing Landscapementioning

confidence: 99%

Rethinking status 1A criteria in pediatric cardiac transplantation: A case for the prioritization of patients with single ventricle anatomy supported by ventricular assist devices

Berry

Bearl²

2023

Front. Pediatr.

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Over the past 2 years advancements in the techniques and technology of pediatric heart transplantation have exponentially increased. However, even as the number of pediatric donor hearts has grown, demand for this limited resource continues to far outpace supply. Thus, lifesaving support in the form of ventricular assist devices (VAD) has become increasingly utilized in bridging pediatric patients to cardiac transplant. In the current pediatric heart transplant listing criteria, adopted by the United Network for Organ Sharing (UNOS) in 2016, all pediatric patients with a VAD are granted 1A status and assigned top transplant priority regardless of their underlying pathology. However, should this be the case? We suggest that the presence of a VAD alone may not be sufficient for status 1A listing. In doing so, we specifically highlight the heightened acuity, resource utilization, risk profile, and diminished outcomes in patients with single ventricle physiology supported with VAD as compared to patients with structurally normal hearts who would both be listed under 1A status. Given this, from a distributive justice perspective, we further suggest that the lack of granularity in current pediatric cardiac transplant listing categories may inadvertently lead to an inequitable distribution of donor organs and hospital resources especially as it pertains to those with single ventricle anatomy on VAD support. We propose revisiting the current listing priorities in light of improved techniques, technology, and recent data to mitigate this phenomenon. By doing this, pediatric patients with single ventricle disease might be more equitably stratified while awaiting heart transplant.

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Section: Mechanical Circulatory Support: a Changing Landscapementioning

confidence: 99%

Rethinking status 1A criteria in pediatric cardiac transplantation: A case for the prioritization of patients with single ventricle anatomy supported by ventricular assist devices

Berry

Bearl²

2023

Front. Pediatr.

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“…4 Currently, the only widely used Food and Drug Administration (FDA)-approved device for long-term pediatric MCS is the Berlin heart 5,6 -a pneumatic pulsatile extracorporeal device that is inserted via central ventricular cannulation. 7 Despite being the most common means for bridge to transplantation in children, 8 it is associated with thrombotic complications and device failure. 9 Adult VADs or ECMO pumps are otherwise being used off-label for circulatory support in children.…”

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confidence: 99%

In-Vivo Evaluation of a Novel Integrated Pediatric Pump Lung in a 30-Day Ovine Animal Model

Leibowitz,

Awad,

Han

et al. 2024

ASAIO Journal

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Recently there has been increased use of mechanical circulatory support in pediatric patients as a bridge to cardiopulmonary recovery or transplantation. However, there are few devices that are optimized and approved for use in pediatric patients. We designed and prototyped a novel integrated pediatric pump lung (PPL) that underwent 30 day in-vivo testing in seven juvenile Dorset Hybrid sheep. Devices were implanted in a right atrial to pulmonary artery configuration. Six of seven sheep survived with a device functioning for 25–35 days. The device flow rate was maintained at 2.08 ± 0.34 to 2.54 ± 0.16 L/min with oxygen transfer of 109.8 ± 24.8 to 151.2 ± 26.2 ml/min over the study duration. Aside from a postoperative drop in hematocrit, all hematologic and blood chemistry test values returned to normal ranges after 1–2 weeks postoperatively. Similarly, lactate dehydrogenase increased postoperatively and returned to baseline. In two sheep, there were early device failures due to oxygenator thrombosis on postoperative days zero and five; they then had oxygenator exchanges with subsequent devices performing stably for 30 days. This study demonstrated that the integrated PPL device exhibited stable performance and acceptable biocompatibility in a 30 day ovine model.

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Machine learning based on computational fluid dynamics enables geometric design optimisation of the NeoVAD blades

Nissim

Karnik²,

Smith³

et al. 2023

Sci Rep

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The NeoVAD is a proposed paediatric axial-flow Left Ventricular Assist Device (LVAD), small enough to be implanted in infants. The design of the impeller and diffuser blades is important for hydrodynamic performance and haemocompatibility of the pump. This study aimed to optimise the blades for pump efficiency using Computational Fluid Dynamics (CFD), machine learning and global optimisation. Meshing of each design typically included 6 million hexahedral elements and a Shear Stress Transport turbulence model was used to close the Reynolds Averaged Navier–Stokes equations. CFD models of 32 base geometries, operating at 8 flow rates between 0.5 and 4 L/min, were created to match experimental studies. These were validated by comparison of the pressure-flow and efficiency-flow curves with those experimentally measured for all base prototype pumps. A surrogate model was required to allow the optimisation routine to conduct an efficient search; a multi-linear regression, Gaussian Process Regression and a Bayesian Regularised Artificial Neural Network predicted the optimisation objective at design points not explicitly simulated. A Genetic Algorithm was used to search for an optimal design. The optimised design offered a 5.51% increase in efficiency at design point (a 20.9% performance increase) as compared to the best performing pump from the 32 base designs. An optimisation method for the blade design of LVADs has been shown to work for a single objective function and future work will consider multi-objective optimisation.

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The importance of mechanical circulatory support on pediatric waitlist and post heart transplant survival: a narrative review

Cited by 4 publications

References 43 publications

Rethinking status 1A criteria in pediatric cardiac transplantation: A case for the prioritization of patients with single ventricle anatomy supported by ventricular assist devices

Rethinking status 1A criteria in pediatric cardiac transplantation: A case for the prioritization of patients with single ventricle anatomy supported by ventricular assist devices

In-Vivo Evaluation of a Novel Integrated Pediatric Pump Lung in a 30-Day Ovine Animal Model

Machine learning based on computational fluid dynamics enables geometric design optimisation of the NeoVAD blades

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