Variability in clinical decision‐making for ventricular assist device implantation in pediatrics

Abstract

Background: Minimal data exist on clinical decision-making in VAD implantation in pediatrics. This study aims to identify areas of consensus/variability among pediatric VAD physicians in determining eligibility and factors that guide decision-making. Methods: An 88-item survey with clinical vignettes was sent to 132 pediatric HT cardiologists and surgeons at 37 centers. Summary statistics are presented for the variables assessed. Results: Total respondents were 65 (72% cardiologists, 28% surgeons) whose centers implanted 1-5 (34%), 6-10 (40%), or >10 (26%) VADs in the past year. Consensus varied by patients' age, diagnosis, and Pedimacs profile. Highest agreement to offer VAD (97%) was a mechanically ventilated teenager with dilated cardiomyopathy. Patients stable on inotropes were less likely offered VAD (11%-25%). SV infant with Pedimacs profile 2 had the most varied responses: 37% offered VAD; estimated survival ranged from 15% to 90%. Variables considered for VAD eligibility included mild developmental delays (100% offered VAD), moderate-severe behavioral concerns (46%), cancer in remission >2 years (100%), active malignancy with good prognosis (68%) or uncertain prognosis (36%), and BMI >35 (74%) or <15 (69%). Most respondents (91%) would consider destination therapy VADs in pediatrics, though not currently feasible at 1/3 of centers. Factors with greatest influence on decision-making included HT candidacy, families' goals of care, and risks of complications. Conclusions: Significant variation exists among pediatric VAD physicians when determining VAD eligibility and estimating survival, which can lead to differences in access to emerging technologies across institutions. Further work is needed to understand and mitigate these differences.

Ventricular Assist Device Outcomes in Infants and Children With Stage 1 Single Ventricle Palliation

“…The ideal threshold and timing of when to consider VAD implantation in this high-risk patient population is not well established, with much variability among VAD centers. 5,6 The literature on VAD outcomes among infants with pre- or poststage 1 palliation is limited to case reports/series or subsets of registry data with mortality on device ranging from 33% to 89% (n range = 4–23). 2,4,7,8…”

Managing uncertainty in decision-making of common congenital cardiac defects

“…biases within paediatric cardiology and surgery, 12 the cardiac catheterisation laboratory, [13][14] the ICU, 15 and even as a framework for decision-making about donor organs in cardiac transplantation, which complicates the process of decision-making still further. 16…”

Management of Advanced Heart Failure in Children with Cancer Therapy-Related Cardiac Dysfunction

“…Even in individuals who are candidates for heart transplant, LVAD therapy can allow for improved hemodynamic support as well as physical and nutritional rehabilitation while awaiting transplant and also provide an opportunity to observe for potential myocardial recovery and cancer recurrence. In a survey focused on decision making regarding VAD therapy for various pediatric populations, there was variability on whether VAD therapy would be considered for patients with CTRCD across centers depending on the proximity to cancer illness, need for ongoing chemotherapy, and overall prognosis [49]. This may reflect the evolving nature of pediatric MCS support in utilizing VADs in more complex patient populations along with a limited understanding of the efficacy of these therapies on how they may impact long-term survival and quality of life, especially in the setting of other high-risk comorbidities.…”