Clinical and Molecular Comparison of Pediatric and Adult Reverse Remodeling With Ventricular Assist Devices

Ventricular assist device (VAD) support induces reverse remodeling of failing myocardium that leads to occasional functional recovery of the adult heart. While there have been numerous clinical reports in adult patients with end-stage cardiomyopathy, little is known about reverse remodeling in children, which has increasing clinical potential with the recent expansion of pediatric VADs in the setting of static organ supply for heart transplantation. Pediatric myocardium also promises theoretical advantages for recovery over adult myocardium due to its greater abundance of cardiac progenitor cells. To identify potential targets of future studies, we conducted a literature review with two aims: (i) to summarize clinical cases of pediatric patients who exhibited cardiac recovery following VAD support; and (ii) to analyze genetic changes in pediatric myocardium induced by VAD support compared with those observed in adult patients. Several clinical series of pediatric VAD cases report that small proportions of their cohorts were weaned off from device support, but a lack of information about the etiology and support duration of these patients limits the ability to determine whether they represent reverse remodeling of myocardial structure or just recovery from acute illness. A comparison of pediatric and adult gene expression changes with VAD support reveals approximately 40% of genes to be oppositely regulated, indicating that the pediatric genetic response is distinct. These observations highlight a necessity to better understand reverse remodeling specific to pediatric myocardium, which is crucial to improving clinical strategies for bridge-to-recovery in children.