Widening care gap in VAD therapy

The impact of pre-transplant ventricular assist device support in pediatric patients with end-stage heart failure on the outcomes of heart transplantation-"a single center experience"

Introduction

The objective of this study was to examine the impact of ventricular assist device support as a bridge to heart transplantation in children with end-stage heart failure. In light of the limited availability of donor organs, particularly in Europe, the number of children requiring ventricular assist device support is rising at an unavoidable rate.

Methods

We performed a retrospective cohort study of patients who underwent a single and primary pediatric heart transplantation. Patients were divided into two groups: with pre transplant ventricular assist device (VAD) support and without VAD support. The primary outcome was survival at the follow-up evaluation. The time point designated as "time 0" was defined as the time of heart transplantation. Secondary outcome was examined by mean of univariable and multivariable logistic regression, severity of cardiac disease based on ECMO-support pre VAD-support, mean waiting time for transplantation, mean OR time and mean length of hospital stay before and after transplantation.

Results

144 patients could be included in the final analysis. The cumulative survival rate at follow-up period was 67 ± 10% in group 1 vs. 60 ± 6% in group 2 (P = 0.769). The mean waiting time (days) on the list was 205 ± 155 in group 1 and 119 ± 69 in group 2 (P = 0.002). The mean length of hospital stay (days) was 214 ± 209 in group 1 and 128 ± 91 days in group 2. Early primary-graft-failure was 10% in group 1 and 13% in group 2. Odds ratio [OR] is as follows: 1.992, 95% confidence interval [CI]: 0.983-1.007, p = 0.266, aortic clamp time per minutes: OR: 1.008, 95% CI: (0.997-1.019), p = 0.164, HLM time per minutes: OR: 0.996, 95% CI: (0.991-1.001), p = 0.146, Operation time per minutes: OR: 1.000, 95% CI: (0.995-1.004), p = 0.861.

Conclusion

The provision of pre-HTx VAD support does not have an adverse effect on the short- and long-term survival of pediatric patients undergoing HTx. A higher mortality rate was observed among children under three months of age with congenital heart disease. The patients who received VAD support were in a critical condition and required more ECMO support. The results demonstrated a statistically significant correlation between prolonged waiting times and length of hospital stay in group 1. More homogeneous and adequately powered cohorts are needed to better understand the impact of VAD support on posttransplant outcomes.

The ACTION VAD registry: A collective five-year experience

BACKGROUND

The Advanced Cardiac Therapies Improving Outcomes Network (ACTION) began in 2018 as a collaborative learning health system committed to improving outcomes in pediatric heart failure, including children and adults with congenital heart disease, supported with ventricular assist devices (VADs). This report describes patient and device characteristics, and outcomes through 1-year post-implant.

METHODS

The ACTION VAD registry report was created from data submitted to the ACTION learning network from April 2018 to June 2023. It includes 1,430 devices implanted in 1,220 pediatric patients (≤18) from 57 sites across North America.

RESULTS

Males comprised 55% of the registry patients. The median age was 3.7 years with a median implant weight of 13.6 kg; 36% of the cohort was <10 kg. Nearly 40% of patients had a primary diagnosis of congenital heart disease (CHD). Patients with CHD represented 26% of VAD implants in 2018 which increased to 42% in 2023 (p=0.03). At implant, 25% of patients were supported with extracorporeal membrane oxygenation (ECMO), 4.9% with dialysis, and 54% were mechanically ventilated. Paracorporeal pulsatile pumps comprised 40.2% of implants, followed in incidence by paracorporeal continuous flow (28.5%), and implantable continuous flow (24.1%). The number of patients in the VAD Registry patients increased from 102 in 2018 to 256 in 2022, partly reflecting increased center participation in ACTION. Overall survival on support at 1 year was 79.2%, and the incidence of stroke was 13.7%. Infants demonstrated the poorest outcomes, with a 1-year survival of 72.9% and a higher incidence of stroke (20.8%).

CONCLUSION

The 5-year ACTION VAD experience highlights the growing collaboration in the pediatric VAD community and changes in clinical practice. More work is needed to improve survival and limit adverse outcomes, especially in younger patients.

Developments and Challenges in Durable Ventricular Assist Device Technology: A Comprehensive Review with a Focus on Advancements in China

Heart transplantation is currently the most effective treatment for end-stage heart failure; however, the shortage in donor hearts constrains the undertaking of transplantation. Mechanical circulatory support (MCS) technology has made rapid progress in recent years, providing diverse therapeutic options and alleviating the dilemma of donor heart shortage. The ventricular assist device (VAD), as an important category of MCS, demonstrates promising applications in bridging heart transplantation, destination therapy, and bridge-to-decision. VADs can be categorized as durable VADs (dVADs) and temporary VADs (tVADs), according to the duration of assistance. With the technological advancement and clinical application experience accumulated, VADs have been developed in biocompatible, lightweight, bionic, and intelligent ways. In this review, we summarize the development history of VADs, focusing on the mechanism and application status of dVADs in detail, and further discuss the research progress and use of VADs in China.