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Against all odds: Mechanical circulatory support as a bridge to pediatric heart transplant
Stepan Maruniak1,2, Oleh Loskutov3,4, Havrylo Kovtun5
1Department of Extracorporeal Methods of Treatment, Heart Institute Ministry of Health of Ukraine, Kyiv, Ukraine.
Insights
Bridging pediatric patients with end-stage heart failure to heart transplant using extracorporeal devices is feasible even in wartime. Adaptable extracorporeal membrane oxygenation (ECMO) and ventricular assist device configurations overcome resource limitations.
Area of Science:
- Pediatric Cardiology
- Cardiovascular Surgery
- Critical Care Medicine
Background:
- End-stage heart failure (ESHF) in children presents significant challenges for heart transplantation (HTx).
- Extracorporeal support devices are crucial for bridging patients to HTx.
- Wartime conditions impose severe logistical and technological limitations on medical care.
Purpose of the Study:
- To evaluate the feasibility of bridging pediatric patients with ESHF to HTx using extracorporeal devices under resource-limited wartime conditions.
- To describe the adaptability of extracorporeal membrane oxygenation (ECMO) and ventricular assist device (VAD) configurations in challenging environments.
Main Methods:
- Two pediatric patients with ESHF received extracorporeal support for bridging to HTx.
- One patient utilized veno-arterial ECMO (V-A ECMO) with left ventricular unloading, later converted to a hybrid VAD configuration.
- The second patient received emergency left ventricular assist device (LVAD) implantation followed by V-A ECMO for primary graft dysfunction.
Main Results:
- Both pediatric patients were successfully bridged to HTx.
- The first patient experienced acute kidney injury and hemorrhagic stroke post-HTx.
- The second patient required continuous renal replacement therapy.
- Both children demonstrated favorable recovery outcomes despite complications.
Conclusions:
- Bridging to HTx in pediatric ESHF is achievable even in resource-limited wartime settings.
- Flexible application of ECMO and VAD unloading strategies can surmount significant logistical and technological hurdles.
- Successful outcomes highlight the resilience and adaptability of advanced cardiac support in critical situations.
Abstract:
Two pediatric patients with dilated cardiomyopathy and end-stage heart failure (ESHF) were bridged with extracorporeal devices to heart transplant (HTx).A 6-year-old boy received veno-arterial extracorporeal membrane oxygenation (V-A ECMO) support with left ventricular unloading via subclavian drainage and later conversion to a hybrid configuration involving left and right ventricular assist devices (LVAD and RVAD) for 8 days. After HTx, acute kidney injury and hemorrhagic stroke occurred.A 12-year-old girl with recurrent cardiac arrests underwent emergency LVAD implantation (EXCOR® Active) for 6 h for bridging to HTx. She received 4 days of V-A ECMO support due to early primary graft dysfunction (PGD) and 9 days of continuous renal replacement therapy. Both children recovered with favorable outcomes.These patients demonstrate that bridging to HTx in ESHF is feasible even under resource-limited wartime conditions. Adaptability in ECMO and the unloading configuration can overcome severe logistical and technological limitations.
