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Rohde S, de By TMMH, Bogers AJJC, Schweiger M. Myocardial recovery in children supported with a durable ventricular assist device-a systematic review. Eur J Cardiothorac Surg 2023; 64:ezad263. [PMID: 37498565 PMCID: PMC10560320 DOI: 10.1093/ejcts/ezad263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 06/18/2023] [Accepted: 07/26/2023] [Indexed: 07/28/2023] Open
Abstract
OBJECTIVES A small percentage of paediatric patients supported with a ventricular assist device (VAD) can have their device explanted following myocardial recovery. The goal of this systematic review is to summarize the current literature on the clinical course in these children after weaning. METHODS A systematic literature search was performed on 27 May 2022 using Embase, Medline ALL, Web of Science Core Collection, Cochrane Central Register of Controlled Trials and Google Scholar to include all literature on paediatric patients supported by a durable VAD during the last decade. Overlapping study cohorts and registry-based studies were filtered out. RESULTS Thirty-seven articles were included. Eighteen of them reported on the incidence of recovery in cohort studies, with an overall incidence rate of 8.7% (81/928). Twenty-two of the included articles reported on clinical outcomes after VAD explantation (83 patients). The aetiologies varied widely and were not limited to diseases with a natural transient course like myocarditis. Most of the patients in the included studies (70; 84.3%) were supported by a Berlin Heart EXCOR, and in 66.3% (55/83), only the left ventricle had to be supported. The longest follow-up period was 19.1 years, and multiple studies reported on long-term myocardial recovery. Fewer than half of the reported deaths had a cardiac cause. CONCLUSIONS Myocardial recovery during VAD support is dependent on various contributing components. The interactions among patient-, device-, time- and hospital-related factors are complex and not yet fully understood. Long-term recovery after VAD support is achievable, even after a long duration of VAD support, and even in patients with aetiologies different from myocarditis or post-cardiotomy heart failure. More research is needed on this favourable outcome after VAD support.
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Affiliation(s)
- Sofie Rohde
- Department of Cardio-thoracic surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | | | - Ad J J C Bogers
- Department of Cardio-thoracic surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Martin Schweiger
- Children′s Hospital Zurich, Pediatric Heart Centre, Department for Congenital Heart Surgery, Zurich, Switzerland
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Kanwar MK, Selzman CH, Ton VK, Miera O, Cornwell WK, Antaki J, Drakos S, Shah P. Clinical myocardial recovery in advanced heart failure with long term left ventricular assist device support. J Heart Lung Transplant 2022; 41:1324-1334. [PMID: 35835680 PMCID: PMC10257189 DOI: 10.1016/j.healun.2022.05.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 05/16/2022] [Accepted: 05/23/2022] [Indexed: 10/18/2022] Open
Abstract
Left ventricular assist-device (LVAD) implantation is a life-saving therapy for patients with advanced heart failure (HF). With chronic unloading and circulatory support, LVAD-supported hearts often show significant reverse remodeling at the structural, cellular and molecular level. However, translation of these changes into meaningful cardiac recovery allowing LVAD explant is lagging. Part of the reason for this discrepancy is lack of anticipation and hence promotion and evaluation for recovery post LVAD implant. There is additional uncertainty about the long-term course of HF following LVAD explant. In selected patients, however, guided by the etiology of HF, duration of disease and other clinical factors, significant functional improvement and LVAD explantation with long-term freedom from recurrent HF events has been demonstrated to be feasible in a reproducible manner. The identified predictors of myocardial recovery suggest that the elective therapeutic use of potentially less invasive VADs for reversal of HF earlier in the disease process is a future goal that warrants further investigation. Hence, it is prudent to develop and implement tools to predict HF reversibility prior to LVAD implant, optimize unloading-promoted recovery with guideline directed medical therapy and monitor for myocardial improvement. This review article summarizes the clinical aspects of myocardial recovery and together with its companion review article focused on the biological aspects of recovery, they aim to provide a useful framework for clinicians and investigators.
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Affiliation(s)
- Manreet K Kanwar
- Cardiovascular Institute, Allegheny Health Network, Pittsburgh, Pennsylvania.
| | - Craig H Selzman
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Van-Khue Ton
- Massachusetts General Hospital, Harvard Medical School, Boston, Maryland
| | - Oliver Miera
- Department of Congenital Heart Disease, Pediatric Cardiology, German Heart Center, Berlin, Germany
| | - William K Cornwell
- Department of Medicine Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - James Antaki
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, New York
| | - Stavros Drakos
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah
| | - Palak Shah
- Inova Heart and Vascular Institute, Falls Church, Virginia
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Antiplatelet and Anticoagulant Strategies Following Left Ventricular Assist Device (LVAD) Explantation or Decommissioning: A Scoping Review of the Literature. Heart Lung Circ 2021; 30:1525-1532. [PMID: 33933364 DOI: 10.1016/j.hlc.2021.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 04/04/2021] [Indexed: 11/23/2022]
Abstract
Mechanical circulatory support using left ventricular assist devices (LVADs) has transformed management of patients with end-stage heart failure with more patients on LVAD therapy surviving long enough to necessitate either device explantation or decommissioning. Usually, there is foreign material retained following these procedures that requires maintaining antiplatelet and/or anticoagulant therapy. However, there is no consensus on optimal management of antiplatelet and anticoagulant therapy following LVAD explantation or decommissioning. We conducted a scoping review of antiplatelet and anticoagulation strategies, searching EMBASE, PubMed and CENTRAL. A total of 15 case reports and series encompassing 38 patient cases were found that met inclusion criteria. There was a heterogeneity of LVAD types and techniques used for explantation and decommissioning. Most reports identified in our review maintained patients on a vitamin K antagonist for at least 3 months post-explantation or decommissioning with or without concomitant antiplatelet therapy with low-dose aspirin. However, there was no single agreed-upon optimal strategy for antiplatelet and anticoagulant use post-procedure. Factors such as the degree of foreign material retained following device explantation or decommissioning and whether there is another indication for anticoagulation or antiplatelet use must be considered. A lack of overall consensus indicates that more studies are needed in this area to establish definitive guidelines around antiplatelet and anticoagulant therapy following LVAD explantation or decommissioning.
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McPherson I, Generali T, Reinhardt Z, Chilvers N, Nassar M, De Rita F, Viganò G, Schueler S, Hasan A. HeartWare Explant After Recovery 6 Years After Implant in a 3-Year-Old Child: Has the Game Changed? Ann Thorac Surg 2021; 112:e37-e39. [PMID: 33412138 DOI: 10.1016/j.athoracsur.2020.10.061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 10/08/2020] [Accepted: 10/12/2020] [Indexed: 11/30/2022]
Abstract
The use of continuous-flow mechanical circulatory support in preschool children remains anecdotal. This case report describes the sequel to the implantation with a HeartWare HVAD system (Medtronic, Minneapolis, MN) in a 3-year old child. A 3-year-old boy with myocarditis-related cardiomyopathy underwent implantation with a HeartWare device. After an uncomplicated postoperative course, the patient was discharged home. Serial echocardiography showed progressive left ventricular recovery. After 6 months, the device was decommissioned, and the outflow graft was tied off. Six years after insertion, the device was explanted uneventfully. The HeartWare ventricular assist device offers viable long-term mechanical circulatory support in selected children that results in sustainable care and good quality of life.
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Affiliation(s)
- Iain McPherson
- Department of Cardiothoracic Surgery, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom
| | - Tommaso Generali
- Department of Congenital Cardiac Surgery and Cardiopulmonary Transplantation, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom.
| | - Zdenka Reinhardt
- Department of Pediatric Cardiology and Transplantation, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom
| | - Nicholas Chilvers
- Department of Cardiothoracic Surgery, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom
| | - Mohamed Nassar
- Department of Congenital Cardiac Surgery and Cardiopulmonary Transplantation, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom
| | - Fabrizio De Rita
- Department of Congenital Cardiac Surgery and Cardiopulmonary Transplantation, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom
| | - Gaia Viganò
- Department of Congenital Cardiac Surgery and Cardiopulmonary Transplantation, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom
| | - Stephan Schueler
- Department of Cardiothoracic Surgery, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom
| | - Asif Hasan
- Department of Congenital Cardiac Surgery and Cardiopulmonary Transplantation, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom
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Blood trauma potential of the HeartWare Ventricular Assist Device in pediatric patients. J Thorac Cardiovasc Surg 2020; 159:1519-1527.e1. [DOI: 10.1016/j.jtcvs.2019.06.084] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 06/24/2019] [Accepted: 06/26/2019] [Indexed: 01/19/2023]
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Extracorporeal membrane oxygenation, Berlin, and ventricular assist devices: a primer for the cardiologist. Curr Opin Cardiol 2018; 33:87-94. [PMID: 29059075 DOI: 10.1097/hco.0000000000000479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Mechanical circulatory support (MCS) has become an indispensable tool in the management of children with impending respiratory and cardiac failure. Though extracorporeal membrane oxygenation (ECMO) was classically the only form of support available to pediatric patients, considerable advances have allowed ventricular assist devices (VADs) to become increasingly utilized in children. This review provides an update of recent advances in ECMO and VAD management in children. RECENT FINDINGS The options for mechanical support in infants and small children with end-stage heart failure are limited. As such, the greatest advances in the past decade have come in the successful adoption of the Berlin Heart EXCOR device, with a marked improvement in survival to transplant over ECMO. Further advances have been made in the use of adult VADs in children. For instance, the HeartWare HVAD has been utilized in children as young as 3 years of age, despite being designed for use in adult patients. SUMMARY The availability of mechanical support options for children remains limited to ECMO and a small number of VADs. While outcomes of VAD support in pediatric patients have been promising, further study in smaller and more complex pediatric patients is necessary.
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Dipchand AI, Kirk R, Naftel DC, Pruitt E, Blume ED, Morrow R, Rosenthal D, Auerbach S, Richmond ME, Kirklin JK. Ventricular Assist Device Support as a Bridge to Transplantation in Pediatric Patients. J Am Coll Cardiol 2018; 72:402-415. [DOI: 10.1016/j.jacc.2018.04.072] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 04/20/2018] [Accepted: 04/23/2018] [Indexed: 11/24/2022]
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Mets G, Panzer J, De Wolf D, Bové T. An Alternative Strategy for Bridge-to-Transplant/Recovery in Small Children with Dilated Cardiomyopathy. Pediatr Cardiol 2017; 38:902-908. [PMID: 28357450 DOI: 10.1007/s00246-017-1610-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 03/20/2017] [Indexed: 10/19/2022]
Abstract
Dilated cardiomyopathy in children still has a poor prognosis with high rates of mortality and cardiac transplantation (resp. around 20 and 25%). Awaiting transplantation or possible recovery, these pediatric patients are mechanically supported with extracorporeal membrane oxygenation or a paracorporeal ventricular assist device, both resulting in higher survival rates but also entailing considerable risks of infection, thrombosis, or bleeding. A new indication for an old technique, i.e., pulmonary artery banding, presents itself as an interesting alternative to mechanical circulatory support in selected infants and small children with dilated LV cardiomyopathy and preserved RV function. Here we present a brief review of literature and report on two patients in whom PAB has been successfully implemented as either bridge-to-recovery or bridge-to-transplant.
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Affiliation(s)
- Gilles Mets
- Department of Pediatrics, University Hospital of Ghent, Ghent, Belgium.
| | - Joseph Panzer
- Department of Pediatric Cardiology, University Hospital of Ghent, Ghent, Belgium
| | - Daniël De Wolf
- Department of Pediatric Cardiology, University Hospital of Ghent, Ghent, Belgium
| | - Thierry Bové
- Department of Cardiac Surgery, University Hospital of Ghent, Ghent, Belgium
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Peng E, Kirk R, Wrightson N, Duong P, Ferguson L, Griselli M, Butt T, O'Sullivan JJ, MacGowan GA, Crossland D, Schueler S, Hasan A. An Extended Role of Continuous Flow Device in Pediatric Mechanical Circulatory Support. Ann Thorac Surg 2016; 102:620-7. [PMID: 27130250 DOI: 10.1016/j.athoracsur.2016.02.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 12/16/2015] [Accepted: 02/01/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Mechanical circulatory support in the pediatric population is currently limited to pulsatile ventricular assist devices (VAD). In recent years, the use of durable, newer generation, continuous flow devices have increased substantially among adults with end-stage heart failure. We examined the extended role of this device in the pediatric population (aged less than 18 years). METHODS Between 2010 and 2015, 12 patients (median age 7.1 years; range, 3.7 to 17.0; one third of patients were aged 5 years or less) received a HeartWare ventricular assist device (HVAD; HeartWare, Framingham, MA), 11 for cardiomyopathy and 1 for posttransplant rejection. Right VAD support (n = 5; 42%) was provided by a short-term device (Levitronix, Zurich, Switzerland). RESULTS Overall, 1 patient died (day 638), 8 patients (67%) underwent transplantation, 1 patient (8.3%) recovered, and 2 patients (17%) remain on HVAD. The mean length of support was 150 days (range, 16 to 638). Four patients (33.3%) were discharged home (all left VAD). In the left VAD group (n = 7), 3 patients subsequently received transplants (days 185, 201, and 234, respectively), 1 recovered (day 149), 1 died (day 638), 1 remained on HVAD (day 198), and 1 needed conversion to biventricular assist device (BIVAD [day 73]). In the BIVAD group (n = 5), right VAD was weaned in 3 (60%), all subsequently received transplants, and 2 remained on BIVAD support until transplant (days 16 and 17, respectively). One BIVAD patient required conversion to central cannulation for longer-term support. Four BIVAD patients (80%) were in Interagency Registry for Mechanically Assisted Circulatory Support level 1 before VAD compared with 2 (29%) in the left VAD group (p = not significant). The actuarial survival rate was 100% at 1 year with no neurologic events. CONCLUSIONS The third-generation, continuous flow device can provide durable support in the pediatric population. The selection strategy for patients who benefit most from the device continues to evolve. It is anticipated that a smaller design in the future will benefit an even wider pediatric population with heart failure.
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Affiliation(s)
- Ed Peng
- Cardiopulmonary Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | - Richard Kirk
- Cardiopulmonary Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | - Neil Wrightson
- Cardiopulmonary Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | - Phuoc Duong
- Cardiopulmonary Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | - Lee Ferguson
- Cardiopulmonary Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | - Massimo Griselli
- Cardiopulmonary Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | - Tanveer Butt
- Cardiopulmonary Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | - John J O'Sullivan
- Cardiopulmonary Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | - Guy A MacGowan
- Cardiopulmonary Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | - David Crossland
- Cardiopulmonary Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | - Stephan Schueler
- Cardiopulmonary Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | - Asif Hasan
- Cardiopulmonary Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, United Kingdom.
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