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Published on: July 18, 2014
Biventricular assist devices as a bridge to heart transplantation in small children
Sanjiv K Gandhi1, Charles B Huddleston, David T Balzer
1Division of Cardiothoracic Surgery, Saint Louis Children's Hospital, Suite 5S50, 1 Children's Place, Saint Louis, MO 63110, USA. gandhis@wustl.edu
Insights
Biventricular assist device (BiVAD) support effectively bridges small children to heart transplantation with low mortality. This therapy can also reverse high pulmonary vascular resistance, offering a vital option for pediatric heart failure patients.
Area of Science:
- Pediatric Cardiology
- Mechanical Circulatory Support
- Cardiothoracic Surgery
Background:
- Experience with biventricular assist device (BiVAD) support in small children awaiting heart transplantation is limited.
- Pediatric heart transplant candidates often present with significant right ventricular dysfunction and elevated pulmonary vascular resistance.
Purpose of the Study:
- To evaluate the efficacy and safety of BiVAD support as a bridge to heart transplantation in pediatric patients.
- To assess the impact of BiVAD support on pulmonary vascular resistance in this population.
Main Methods:
- Utilized BiVAD support (Berlin EXCOR) in 9 pediatric heart transplant candidates.
- Patients received support due to significant right ventricular dysfunction, often requiring mechanical ventilation or ECMO prior to BiVAD implantation.
- Monitored pulmonary vascular resistance index (Rpi) and assessed outcomes including bridging to transplant, complications, and post-transplant status.
Main Results:
- Eight out of nine pediatric patients were successfully bridged to heart transplantation after a median BiVAD support duration of 35 days.
- BiVAD support effectively reduced elevated pulmonary vascular resistance in two patients unresponsive to vasodilator therapy.
- Low mortality and morbidity were observed, with no acute neurological or thromboembolic events; one perioperative death occurred in a low-weight infant.
Conclusions:
- Biventricular assist device support is an effective strategy for bridging small children to heart transplantation, demonstrating low mortality and morbidity.
- BiVAD support can successfully reverse elevated pulmonary vascular resistance, providing a crucial therapeutic option.
- Surveillance for HLA antibody sensitization during BiVAD support requires careful interpretation due to potential interference from non-HLA antibodies.
Background:
Experience with the use of biventricular assist device (BiVAD) support to bridge small children to heart transplantation is limited.
Methods And Results:
We used BIVAD support (Berlin EXCOR) in 9 pediatric heart transplant candidates from 4/05 to 7/07. The median patient age was 1.7 years (12 days to 17 years). The median patient weight was 9.4 kg (3 to 38 kg). All children were supported with multiple intravenous inotropes+/-mechanical ventilation (6) or ECMO (3) before BiVAD implantation. All had significant right ventricular dysfunction. The median pulmonary vascular resistance index (Rpi) was 6.0 WU/m(2). Eight patients were successfully bridged to heart transplantation after a median duration of BiVAD support of 35 days (1 to 77 days). One death occurred after 10 days of support from perioperative renal failure in a 3 kg infant. Five patients required at least 1 blood pump change. One patient had a driveline infection requiring treatment. There were no acute neurological complications, no thromboembolic events, and no bleeding complications. In 2 patients with Rpi >10 WU/m(2) unresponsive to pulmonary vasodilator therapy, Rpi dropped to 1.4 and 4.6 WU/m(2), after 33 and 41 days of support, respectively. All 8 survivors underwent successful heart transplantation. Of 5 patients supported >30 days, 3 developed an extremely elevated (>90%) panel reactive antibody by ELISA that was not confirmed by other methods; none had a positive donor-specific retrospective crossmatch. There was 1 episode of rejection (with hemodynamic compromise) in the 8 transplanted patients. Rpi was normal (<3 WU/m(2)) without pulmonary vasodilators in all patients within 3 months after transplant. There have been no deaths after transplant with a median follow-up of 19 months.
Conclusions:
BiVAD support can effectively be used in small children as a bridge to heart transplantation and can be accomplished with low mortality and morbidity. BiVAD support may offer an additional means to reverse extremely elevated pulmonary vascular resistance. Surveillance for HLA antibody sensitization during BiVAD support may be complicated by the development of non-HLA antibodies which may not reflect true HLA presensitization.
