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Published on: June 12, 2021
Predicting Stroke for Pediatric Patients Supported With Ventricular Assist Devices: A Pedimacs Report
Awais Ashfaq1, Angela Lorts1, David Rosenthal2
1Division of Cardiovascular Surgery, Department of Surgery, Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
Insights
Stroke risk in pediatric ventricular assist device (VAD) patients has decreased, especially with paracorporeal pulsatile devices. Risk factor analysis helps refine management for better outcomes in VAD therapy.
Area of Science:
- Pediatric Cardiology
- Mechanical Circulatory Support
- Neurology
Background:
- The Pediatric Interagency Registry for Mechanical Circulatory Support (Pedimacs) database offers insights into pediatric patients requiring ventricular assist devices (VADs).
- Stroke is a significant complication in pediatric VAD recipients, necessitating identification of risk factors and trends.
Purpose of the Study:
- To analyze stroke incidence in pediatric patients receiving VADs using Pedimacs data.
- To identify key variables influencing stroke risk in this population.
Main Methods:
- Utilized multiphase parametric hazard modeling on data from 1219 pediatric patients (aged <19) implanted with 1463 VADs between 2012 and 2022.
- Analyzed stroke risk factors across different VAD types and patient demographics.
Main Results:
- Overall freedom from stroke at 6 months improved from 80.2% (2012-2016) to 87.9% (2017-2023).
- Implantable continuous VADs showed the highest stroke-free rates (91.1% at 6 months).
- Early stroke risk decreased significantly in the recent era (hazard ratio, 5.01), particularly for paracorporeal pulsatile devices.
Conclusions:
- The overall stroke rate in pediatric VAD patients has decreased, with notable improvements in paracorporeal pulsatile device recipients.
- Risk factor analysis provides crucial information for identifying high-risk patients and optimizing VAD management strategies.
Background:
The Pediatric Interagency Registry for Mechanical Circulatory Support (Pedimacs) provides detailed understanding on pediatric patients supported with ventricular assist devices (VADs). We sought to identify important variables affecting the incidence of stroke in pediatric VADs.
Methods:
Between 2012 and 2022, 1463 devices in 1219 patients were reported to Pedimacs from 40 centers in patients aged <19 years at their first VAD implantation. Multiphase parametric hazard modeling was used to identify risk factors for stroke among all device types.
Results:
Of the 1219 patients, the most common devices were implantable continuous (472 [39%]), followed by paracorporeal pulsatile (342 [28%]), and paracorporeal continuous (327 [27%]). Overall freedom from stroke at 6 months was higher in the recent era (2012-2016; 80.2% [95% CI, 77.1%-82.9%] vs 2017-2023; 87.9% [95% CI, 86.2%-89.4%], P = .009). Implantable continuous VADs had the highest freedom from stroke at 3 months (92.7%; 95% CI, 91.1%-93.9%) and 6 months (91.1%; 95% CI, 89.3%-92.6%), followed by paracorporeal pulsatile (87.0% [95% CI, 84.8%-88.9%] and 82.8% [95% CI, 79.8%-85.5%], respectively), and paracorporeal continuous (76.0% [95% CI, 71.8%-79.5%] and 69.5% [95% CI, 63.4%-74.8%], respectively) VADs. Parametric modeling identified risk factors for stoke early after implant and later. Overall, and particularly for paracorporeal pulsatile devices, early stroke risk has decreased in the most recent era (hazard ratio, 5.01). Among implantable continuous devices, cardiogenic shock was the major risk factor. For patients <10 kg, early hazard was only seen in the previous era. For congenital patients, early hazard was seen in nonimplantable device use and use of extracorporeal membrane oxygenation.
Conclusions:
The overall stroke rate has decreased from 20% to 15% at 6 months, with particular improvement among paracorporeal pulsatile devices. Risk factor analyses offer insights for identification of higher stroke risk subsets and further management refinements.
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