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Published on: May 11, 2018
Long-term implantable ventricular assist device support in children
Junsang Cho1, Hari P Tunuguntla2, Sebastian C Tume3
1Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex.
Insights
Pediatric implantable continuous-flow ventricular assist devices (IC-VAD) can be managed at home, offering long-term support beyond temporary bridging for heart transplants. This approach improves outcomes and survival rates for children with heart failure.
Area of Science:
- Pediatric Cardiology
- Mechanical Circulatory Support
- Cardiothoracic Surgery
Background:
- Pediatric implantable continuous-flow ventricular assist devices (IC-VAD) are typically used as temporary support for children awaiting heart transplantation.
- These devices bridge patients to transplant within the same hospital admission.
Purpose of the Study:
- To evaluate the feasibility and outcomes of outpatient management for pediatric IC-VAD support.
- To assess the long-term efficacy of IC-VADs beyond their role as a temporary bridge to transplantation.
Main Methods:
- A retrospective review of pediatric patients who received IC-VAD support between 2008 and 2022 at a tertiary pediatric heart center.
- Analysis of patient demographics, device types, etiologies of heart failure, and clinical outcomes, including home discharge and survival rates.
Main Results:
- Out of 100 IC-VAD encounters, 94% achieved positive outcomes at 6 months (ongoing support, transplant, or recovery).
- 82% of patients were discharged home with VAD support, experiencing significantly reduced morbidity rates post-discharge.
- Overall survival at 1, 2, and 5 years was 90%, 86%, and 77%, respectively, with infection and stroke being primary causes of negative outcomes.
Conclusions:
- Outpatient management of pediatric IC-VAD support is feasible.
- Long-term VAD support can maximize the potential of these devices, extending their use beyond temporary bridging for heart transplantation.
Background:
In pediatrics, implantable continuous-flow ventricular assist devices (IC-VAD) are often used as a "temporary" support, bridging children to cardiac transplantation during the same hospital admission.
Methods:
We conducted a retrospective review of our consecutive patients undergoing IC-VAD support at a tertiary pediatric heart center between 2008 and 2022.
Results:
We identified 100 IC-VAD implant encounters: HeartWare HVAD (67; 67%), HeartMate II (17; 17%), and HeartMate 3 (16; 16%). The median (range) age, weight, and body surface area at implantation were 14.1 (3.0-56.5) years, 54.8 (13.3-140) kg, and 1.6 (0.6-2.6) m2, respectively. Cardiomyopathy (58; 58%) was the most common etiology, followed by congenital heart disease (37; 37%, including 13 single ventricle). At 6 months of IC-VAD support, 94 (94%) encounters achieved positive outcomes: ongoing support (59; 59%), transplant (33; 33%), and cardiac recovery (2; 2%). Eighty-two encounters (82%) resulted in home discharge with ongoing VAD support, including 38 (46%, out of 82) requiring readmission and 7 (9%, out of 82) resulting in death. There was a clinically significant decrease in morbidity rates before versus after home discharge: bleeding (1.55 vs 0.06), infection (0.84 vs 0.37), and stroke (0.84 vs 0.15 event per patient-year). Overall, 86 encounters (86%) reached positive end points at the latest follow-up (64 transplant, 15 ongoing support, and 7 recovery). Infection (29%; 4 of 14) was the most common cause of negative outcomes, followed by cerebrovascular accident (21%; 3), and unresolved frailty (21%; 3). The estimated overall survival at 1, 2, and 5 years was 90%, 86%, and 77%, respectively.
Conclusions:
This study suggests the feasibility of outpatient management of pediatric IC-VAD support. The ability to offer true long-term support maximizes the potential of IC-VAD support, not limited to a temporary bridging tool for heart transplantation.
