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Mechanical circulatory support in the Dutch National Paediatric Heart Transplantation Programme
Marijke H van der Meulen1, Michiel Dalinghaus2, Alexander P W M Maat3
1Department of Pediatric Cardiology, Erasmus Medical Center, Rotterdam, Netherlands Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, Netherlands.
Insights
Mechanical circulatory support (MCS) with a ventricular assist device (VAD) halved waiting list mortality in children awaiting heart transplantation. Despite significant risks, VADs improve survival for pediatric end-stage heart failure patients.
Area of Science:
- Pediatric Cardiology
- Cardiovascular Surgery
- Transplantation Medicine
Background:
- Terminal heart failure in children presents significant challenges.
- Mechanical circulatory support (MCS) with ventricular assist devices (VADs) offers a potential solution.
- VADs can serve as a bridge to heart transplantation (HTx) or recovery.
Purpose of the Study:
- To evaluate the impact of MCS-VAD on waiting list mortality in pediatric HTx candidates.
- To analyze the outcomes and complications associated with VAD use in this population.
Main Methods:
- Retrospective single-center cohort study.
- Inclusion of all children eligible for HTx since the introduction of MCS-VAD in 2006.
- Analysis of VAD implantation, survival rates, adverse events, and causes of death.
Main Results:
- Out of 43 eligible patients, 18 received a VAD (42%).
- Survival to HTx or recovery was 61% (11 patients).
- Waiting list mortality decreased from 44% to 21% post-MCS-VAD introduction, with VAD complications being a primary cause.
Conclusions:
- MCS-VAD significantly reduced waiting list mortality in pediatric HTx candidates.
- VADs are crucial for improving outcomes in children with end-stage heart failure.
- Despite associated mortality and morbidity, VADs are essential, highlighting the urgent need for donor organs.
Objectives:
Mechanical circulatory support (MCS) with a ventricular assist device (VAD) as a bridge to heart transplantation (HTx) or recovery may improve outcome in children with terminal heart failure. We report our experience with MCS in children eligible for HTx and its effect on waiting list mortality.
Methods:
Retrospective single-centre cohort study, National Paediatric HTx Programme including all children eligible for HTx, since the introduction of MCS-VAD in 2006.
Results:
A total of 43 patients were eligible for HTx, median age 11.7 years [Inter Quartile Range (IQR) 3.0-14.7]. In 18 patients, (42%) a VAD was implanted, 11 (61%) survived to HTx (n = 9) or recovery (n = 2). Techniques and devices used were left ventricular assist device (n = 16, 89%), in 4 cases preceded by extracorporeal membrane oxygenation (ECMO), and biventricular assist device (n = 2, 11%), both preceded by ECMO. In the VAD group, median time to death (n = 7) was 18 days (IQR 7-75), median time to HTx (n = 9) 66 days (IQR 33-223) and 2 patients recovered after 30 and 308 days. The main cause of death on MCS was neurological injury in 4 patients (22%) and systemic thrombo-embolic events in 2 (11%). The most common serious adverse events included confirmed thrombus requiring pump replacement (in 11 patients, 61%) and pericardial effusion leading to rethoracotomy (in 5 patients, 28%). Compared with the era before MCS (1998-2006), waiting list mortality decreased from 44 to 21%, and is now mainly related to complications of VAD support.
Conclusions:
Since the introduction of MCS-VAD, waiting list mortality halved and more children with end-stage heart failure survived to heart transplantation, thus improving outcome. Although there is substantial mortality and morbidity, overall mortality decreases, making MCS-VAD an essential therapeutic tool. The need for donor organs remains critically urgent.