Preliminary Single Center North American Experience With The Berlin Heart Pediatric EXCOR Device

Ventricular assist device application with the intermediate use of a membrane oxygenator as a bridge to pediatric heart transplantation

Extracorporeal membrane oxygenation and ventricular assist devices are currently used for the treatment of severe heart failure as a bridge to transplantation. The use of ventricular assist devices is limited by respiratory failure. We report a patient with severe heart failure and respiratory failure who was successfully bridged to transplantation, initially with extracorporeal membrane oxygenation and afterwards with an EXCOR biventricular assist device (Berlin Heart AG, Berlin, Germany) and a membrane oxygenator (Jostra Quadrox D, Maquet Cardiopulmonary, AG Hirrlingen, Germany) intercalated in the outflow cannula of the left pump.

Optimal time for initiating extracorporeal membrane oxygenation

The technical evolution of extracorporeal membrane oxygenation (ECMO) coincides with the vast improvement in intensive care medicine of the past 4 decades. Extracorporeal circulatory technology substitutes for acutely failed cardiac or pulmonary function until these organs regain sustainable function through goal-oriented intensive care practice. The technology has been validated to improve survival in select patients who would otherwise have 100% mortality. This is by far the most complex life-sustaining technology employed and thus can contribute significant risks such that the decision to institute ECMO requires prompt risk and benefit analysis. Delaying the institution of ECMO may cause irreversible pulmonary and cardiac injuries in addition to other organs. Therefore, the optimal time of initiating ECMO support is crucial to the survival of a critically ill patient.

Bridge to cardiac transplant in children: Berlin Heart versus extracorporeal membrane oxygenation

BACKGROUND

For small children requiring mechanical circulatory support as a bridge to transplantation (BTT), extracorporeal membrane oxygenation (ECMO) has been the only option until the recent introduction of the Berlin Heart EXCOR ventricular assist device (Berlin Heart AG, Berlin, Germany). We reviewed our recent experience with these two technologies with particular focus on early outcomes.

METHODS

Data for 55 consecutive children undergoing BTT between 2001 and 2008 were abstracted from an institutional database. The analysis excluded 13 patients because EXCOR was not used for acute postcardiotomy BTT. Patients were divided into ECMO (n = 21) and EXCOR groups (n = 21). Specific end points included survival to transplant, overall survival, and bridge to recovery. Incidences of adverse events and the duration of support were determined.

RESULTS

Groups were similar in weight, age, and etiologies of heart failure. Likewise, the incidences of stroke and multisystem organ failure were similar. Survival to transplant, recovery, or continued support was 57% in ECMO and 86% in EXCOR (p = 0.040). EXCOR patients had overall significantly better survival (p = 0.049). Two ECMO patients and 1 EXOR patient were bridged to recovery. The mean duration of support was 15 +/- 12 days in the ECMO group and 42 +/- 43 days in the EXCOR group (p < 0.001).

CONCLUSIONS

In children requiring BTT, EXCOR provided substantially longer support times than ECMO, without significant increase in the rates of stroke or multisystem organ failure. Survival to transplant and long-term survival was higher with EXCOR.