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Improving Mechanical Circulatory Support Outcomes in Failing Bidirectional Glenn Physiology
Ryan L Kobayashi1, Ryan J Williams2, Kimberlee Gauvreau2
1Departments of Cardiology and Pediatrics, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA. Ryan.Kobayashi@cardio.chboston.org.
Insights
Mechanical circulatory support (MCS) in failing bidirectional Glenn (BDG) physiology shows improved outcomes. A staged strategy and bivalirudin anticoagulation reduced adverse events and increased transplant rates in pediatric patients.
Area of Science:
- Pediatric Cardiology
- Cardiovascular Surgery
- Critical Care Medicine
Background:
- Mechanical circulatory support (MCS) is associated with high morbidity and mortality in patients with failing bidirectional Glenn (BDG) physiology.
- Optimizing MCS strategies is crucial for improving outcomes in this complex pediatric population.
Purpose of the Study:
- To evaluate the impact of changes in MCS strategies and anticoagulation on outcomes in children with BDG physiology.
- To compare outcomes before and after 2018, focusing on transplant rates and hemocompatibility-related adverse events.
Main Methods:
- Retrospective analysis of 14 pediatric patients with BDG physiology requiring MCS.
- Comparison of two cohorts: pre-2018 (variable anticoagulation, diverse MCS) and post-2018 (staged support, bivalirudin).
- Assessment of transplant rates, duration of support, and major hemocompatibility-related adverse events (MHRAEs).
Main Results:
- The post-2018 cohort (n=7) demonstrated improved transplant rates (71% vs. 43%) compared to the pre-2018 cohort (n=7).
- Total patient-days of support significantly increased in the post-2018 group (1260 vs. 536 days).
- Major hemocompatibility-related adverse event rates were substantially reduced post-2018 (24 vs. 63 per 100 patient-months).
Conclusions:
- A staged MCS strategy (ECMO to pulsatile VAD) combined with bivalirudin anticoagulation has improved survival and reduced adverse events in pediatric patients with BDG physiology.
- These findings suggest that refined MCS protocols can enhance outcomes despite the inherent challenges of this cardiac condition.
- Further research into optimized anticoagulation and device strategies is warranted for this vulnerable population.
Abstract:
There remains high morbidity and mortality with mechanical circulatory support (MCS) in failing bidirectional Glenn (BDG) physiology. We performed a retrospective analysis of children with BDG physiology supported with MCS before and after 2018. Fourteen patients met inclusion criteria (median age 1.5 years, weight 9 kg). Prior to 2018 (n = 7), with variable anticoagulation and strategies including pulsatile VAD, continuous flow VAD, and extracorporeal membrane oxygenation (ECMO), 3 (43%) of patients were transplanted with a total of 536 patient-days of support (median 59 days). Major hemocompatability-related adverse event (MHRAE) rate was 63 per 100 patient-months. After 2018 (n = 7), using a staged support strategy (ECMO to pulsatile VAD) and bivalirudin anticoagulation, 5 (71%) patients were transplanted with a total of 1260 patient-days of support (median 188 days) and MHRAE rate of 24 per 100 patient-months. Despite challenging physiology, we have observed improved survival and reduced MHRAE despite longer support duration.
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