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A decade of pediatric mechanical circulatory support before and after cardiac transplantation
Jonathan M Chen1, Marc E Richmond, Kevin Charette
1Weill Medical College of Cornell University, New York, NY, USA. Jmc23@columbia.edu
Insights
Pediatric mechanical circulatory support, including ventricular assist devices (VADs) and extracorporeal membrane oxygenation (ECMO), effectively bridges children to heart transplantation and aids post-transplant recovery. Smaller devices are needed to reduce complications in the smallest patients.
Area of Science:
- Pediatric cardiology
- Cardiovascular surgery
- Transplantation medicine
Background:
- Mechanical circulatory support (MCS) is crucial for pediatric patients awaiting heart transplantation.
- Extracorporeal membrane oxygenation (ECMO) and ventricular assist devices (VADs) are primary MCS options.
- Assessing the efficacy and outcomes of MCS before and after pediatric heart transplantation is essential.
Purpose of the Study:
- To review the utilization of pediatric mechanical circulatory support (MCS) prior to and following heart transplantation.
- To examine current outcomes and identify future strategies for MCS in pediatric transplantation.
Main Methods:
- A retrospective review of pediatric patients listed for heart transplantation between January 2000 and December 2010.
- Inclusion criteria: patients requiring ECMO or VAD support either pre- or post-transplantation.
- Data collected: indications for support, patient demographics, support duration, complications, mortality causes, and survival rates.
Main Results:
- Ventricular assist device (VAD) support was used in 37 patients, with 86.5% surviving to transplantation.
- Complications like hemorrhage and thrombosis were noted in patients under 15 kg on VADs.
- Extracorporeal membrane oxygenation (ECMO) bridged 14 of 28 patients to transplantation; 19 patients required post-transplant ECMO.
- A significant difference in survival post-listing was observed between patients supported with ECMO, VAD, and those without MCS (P = .02).
Conclusions:
- Both VAD and ECMO are effective in bridging pediatric patients to heart transplantation and supporting them post-transplant.
- The development of smaller devices is crucial to mitigate anticoagulation-related morbidity in the smallest pediatric patients.
- MCS plays a vital role in improving outcomes for pediatric heart transplant candidates.
Objectives:
We reviewed the use of pediatric mechanical circulatory support before and after transplantation to examinine current results and future strategies.
Methods:
All patients listed for transplantation from January 2000 to December 2010 who required either extracorporeal membrane oxygenation (ECMO) or ventricular assist device (VAD) support before ("intention to transplant") or after transplantation were included. Indications for mechanical assistance, age, weight, duration of support, complications while on support, causes of death, and overall actuarial survival were recorded.
Results:
Thirty-seven patients were received VADs; 32 (86.5%) survived to transplantation. Postoperative hemorrhagic or thrombotic complications affected all of those under 15 kg. One patient in the survivor cohort demonstrated focal neurologic findings. Three (8.1%) had panel reactive antibody levels of 10% or more while on device support; all received transplants. ECMO as an intention to bridge to transplantation was used in 28 patients; 7 died, 7 were weaned, and 14 were bridged to transplantation. Nineteen patients required ECMO after transplantation; 3 additional patients had percutaneous VAD support for late rejection. There was a significant (P = .02) difference in survival after listing for transplantation among those supported with ECMO, with VAD, and those not supported with a device. No difference in posttransplant survival was demonstrated between those patients supported with either ECMO or VAD before transplant compared with all others not bridged to transplantation.
Conclusions:
Both VAD and ECMO support are highly effective means of bridging patients to transplantation and supporting patients after transplanatation. Ideally, the availability of smaller devices for children will have a favorable impact on the morbidity related to anticoagulation in the smallest patients.
