Ventricular Assist Device Support in Children and Adolescents With Heart Failure: The Children's Medical Center of Dallas Experience

Abstract

Children with heart failure unresponsive to medical therapy are left with few options for survival. Ventricular assist devices (VADs) are life-saving options for such patients, allowing for bridge to transplantation or cardiac recovery. Retrospective review of cases from May 2006 to October 2010 was undertaken. Fourteen patients underwent implantation of VADs for refractory heart failure. Mean age was 9 years (range 1-17 years), and weight was 41 kg (range 9.7-71 kg). Indications for support: end-stage cardiomyopathy (n = 8), myocarditis (n = 3), univentricular failure (n = 2), and congenital heart disease/postcardiotomy (n = 1). Level of limitation at time of implant included critical cardiogenic shock in six (43%) and progressive decline in eight (57%). Extracorporeal membrane oxygenation was used as a bridge to VAD in five (36%) patients. Preimplant variables: 86% of patients requiring mechanical ventilation (mean 10.3 days), hyperbilirubinemia in 75%, and acute renal insufficiency in 79%. Device selection was systemic VAD in 11 (79%) and biventricular assist device in three (21%). Berlin Heart EXCOR was used in eight patients, while six patients received a Thoratec implantable VAD or paracorporeal VAD. Mean duration of support was 68 days (range 8-363 days). Overall survival was 79%. Ten patients (71%) were successfully bridged to transplantation, three (21%) died while on a device, one remains on support, and no patients were weaned from VAD. Children supported for single ventricle heart failure had a 50% survival with none currently bridged to transplantation. Complications included bleeding requiring reoperation in 21% (n = 3), stroke in 29% (n = 4), and driveline infections in 7% (n = 1). In two patients, a total of six pump exchanges were performed for thrombus formation. Survival for pediatric patients of all ages is excellent using current device technology with a majority of patients being successfully bridged to transplantation. Morbidity is acceptably low considering the severity of illness. Significant challenges exist with long-term extracorporeal support due to lack of donor availability and the high incidence of preformed alloantibodies especially in the failing single ventricle.

Organ allocation in adults with congenital heart disease listed for heart transplant: Impact of ventricular assist devices

“…All of these occur in the context of normal systolic function of the systemic single ventricle. VAD use in the systemic circulation is therefore not a suitable solution for “Fontan failure.” 17, 18 To support the pulmonic circulation, VAD implant requires complex cannulation, 19 and is currently reported only anecdotally, 20, 21 often without successful outcome. 22 Novel pump designs have been proposed specifically for Fontan patients to address this problem, 19, 23 with the expectation that successful utilization may favorably impact transplant candidacy and outcome.…”

“…We did not study children, in whom unique issues are often raised, though bridging to transplant with VAD has been done successfully. 21, 35 …”

Long‐Term Mechanical Circulatory Support in Pediatric Patients

“…Fraser et al (21) reported a 57% incidence of infectious complications in BH patients. In HeartWare patients, the reported incidence of infections of the driveline exit site varies between 7 and 47% (22,23). The first four patients (44.4%) in our group with the HeartWare system presented with infection of the driveline exit site.…”

Anticoagulation Therapy Trends in Children Supported by Ventricular Assist Devices

“…We believe that this reflects on ongoing learning curve as more and more pediatric VADs are used. 2,4,11,12,14,15 It appears that patient age is a significant driver for choice of pharmacotherapy. For example, enoxaparin was more frequently used in younger patients, likely because of the difficulty of warfarin management in this patient group.…”

“…[2][3][4][5][6] Indications for VAD support include myocarditis, inherited cardiac myopathies, dilated cardiomyopathy, acute rejection of heart transplantation, and congenital heart disease. 2,4,7,[9][10][11][12][13] Anticoagulation in pediatric VAD patients has likely undergone an evolution as best practices, and ideal methods are elucidated based on clinical experience.…”