Technology Insight: use of ventricular assist devices in children

Leitlinie Myokarditis der Deutschen Gesellschaft für Pädiatrische Kardiologie

This consensus statement presents updated recommendations on diagnosis and treatment of myocarditis in childhood.

Acute Myocarditis in Children: An Overview of Treatment and Recent Patents

BACKGROUND

Pediatric myocarditis is rare but challenging. This overview summarized the current knowledge and recent patents on childhood myocarditis.

METHODS

Clinical queries and keywords of "myocarditis" and "childhood" were used as search engine.

RESULTS

Viral infections are the most common causes of acute myocarditis. Affected children often have a prodrome of fever, malaise, and myalgia. Clinical manifestations of acute myocarditis in children can be nonspecific. Some children may present with easy fatigability, poor appetite, vomiting, abdominal pain, exercise intolerance, respiratory distress/tachypnea, dyspnea at rest, orthopnea, chronic cough with wheezing, chest pain, unexplained tachycardia, hypotension, syncope, and hepatomegaly. Supraventricular arrhythmias, ventricular arrhythmias, and heart block may be present. A subset of patients have fulminant myocarditis and present with cardiovascular collapse, which may progress to severe cardiogenic shock, and even death. A high index of suspicion is crucial to its diagnosis and timely management. Cardiac magnetic resonance imaging is important in aiding clinical diagnosis while, endomyocardial biopsy remains the gold standard. The treatment consists of supportive therapy, ranging from supplemental oxygen and fluid restriction to mechanical circulatory support. Angiotensinconverting enzyme inhibitors, angio-tensin II receptor blockers, β-blockers, and aldosterone antagonists might be used for the treatment of heart failure while, immunosuppression treatments remain controversial. There are a few recent patents targeting prevention or treatment of viral myocarditis, including an immunogenic composition comprising a PCV-2 antigen, glutathione-S-transferase P1, neuregulins, NF-[kappa] B inhibitor, a pharmaceutical composition which contains 2-amino-2- (2- (4-octyl phenyl) - ethyl) propane 1,3-diol, a composition containing pycnojenol, Chinese herbal concoctions, and a Korean oral rapamycin. Evidence of their efficacy is still lacking.

CONCLUSION

This article reviews the current literature regarding etiology, clinical manifestations, diagnosis, and management of acute myocarditis in children.

Complications in children with ventricular assist devices: systematic review and meta-analyses

Heart failure is a significant cause of mortality in children with cardiovascular diseases. Treatment of heart failure depends on patients' symptoms, age, and severity of their condition, with heart transplantation required when other treatments are unsuccessful. However, due to lack of fitting donor organs, many patients are left untreated, or their transplant is delayed. In these patients, ventricular assist devices (VADs) are used to bridge to heart transplant. However, VAD support presents various complications in patients. The aim of this study was to compile, review, and analyse the studies reporting risk factors and aetiologies of complications of VAD support in children. Random effect risk ratios (RR) with 95% confidence intervals were calculated to analyse relative risk of thrombosis (RR = 3.53 [1.04, 12.06] I² = 0% P = 0.04), neurological problems (RR = 0.95 [0.29, 3.15] I² = 53% P = 0.93), infection (RR = 0.31 [0.05, 2.03] I² = 86% P = 0.22), bleeding (RR = 2.57 [0.76, 8.66] I² = 0% P = 0.13), and mortality (RR = 2.20 [1.36, 3.55] I² = 0% P = 0.001) under pulsatile-flow and continuous-flow VAD support, relative risk of mortality (RR = 0.45 [0.15, 1.37] I² = 36% P = 0.16) under left VAD and biVAD support, relative risk of thrombosis (RR = 1.72 [0.46, 6.44] I² = 0% P = 0.42), infection (RR = 1.77 [0.10, 32.24] I² = 46% P = 0.70) and mortality (RR = 0.92 [0.14, 6.28] I² = 45% P = 0.93) in children with body surface area < 1.2 m² and > 1.2 m² under VAD support, relative risk of mortality in children supported with VAD and diagnosed with cardiomyopathy and congenital heart diseases (RR = 1.31 [0.10, 16.61] I² = 73% P = 0.84), and cardiomyopathy and myocarditis (RR = 0.91 [0.13, 6.24] I² = 58% P = 0.92). Meta-analyses results show that further research is necessary to reduce complications under VAD support.

The role of ventricular assist device in children

The first and successful implantation of a ventricular assist device in 1990 has allowed an 8-year-old child with an end-stage heart failure to undergo a heart transplantation. This milestone paved the way to consider support with ventricular assist in the armamentarium of heart failure management in infants, children and adolescents. Several systems have evolved and faded owing to unacceptable complications. Indications and contraindications to implantation have been established. Anticoagulation management is still on its way to impeccability. Despite the challenges, issues and concerns revolving around ventricular assist devices, the system definitely supports pediatric patients with end-stage heart failure until heart transplantation and could allow recovery of the myocardium.

Heart transplantation: the Berlin experience and perspectives

In patients with end-stage heart failure, heart transplants are now an ingrained practice, as they provide satisfying long-term results with good predictability and quality of life. The successful outcome has evolved from the development of effective immunosuppression, recognition of allograft rejection through diagnostic modalities and improvement in donor organ perfusion. Unfortunately, transplant availability is constrained by the shortage of donor organs and is therefore considered a casuistic therapy. The outcome is defined by unwanted effects of immunosuppressants, increased tumor occurrence and chronic transplant angiopathies. In the long term, patients fear primarily the occurrence of renal insufficiency and secondly osteoporosis with its skeletal complications and corresponding pain. Nevertheless, the overall quality of life is not very limited; on the contrary, patients demonstrate a surprisingly meaningful lives 10-20 years after the transplant. Their physical presentation is similar to those with varying co-morbidities. Most of the 20-year surviving patients are physically active and happy with their daily lives. Medical ambition has seen heart transplantation become reality and develop into an influential force regarding heart surgery, immunology, pharmacology, organ logistics and medical ethics. Its development has also molded our definitions of death and has driven public and health care approval of medical advances. It has provided a strong solidarity among politicians, sociologists, physicians and citizens. Problems regarding ethics continue to endure, and will forecast heart transplants as a defining, but temporary era in human medicine. The donor organ shortage has stimulated the use of resuscitated donor hearts and encouraged exploration and advancement of mechanical circulatory support systems and xenotransplantation as alternatives in the management of end-stage heart failure.

Pediatric ventricular assist devices: what are the key considerations and requirements?

Introduction: The development of ventricular assist devices (VADs) have enabled myocardial recovery and improved patient survival until heart transplantation. However, device options remain limited for children and lag in development.Areas covered: This review focuses on the evolution of pediatric VADs in becoming to be an accepted treatment option in advanced heart failure, discusses the classification of VADs available for children, i.e. types of pumps and duration of support, and defines implantation indications and explantation criteria, describes attendant complications and long-term outcome of VAD support. Furthermore, we emphasize the key considerations and requirements in the application of these devices in infants, children and adolescents.Expert opinion: Increasing use of VADs has facilitated a leading edge in management of advanced heart failure either as a bridge to transplantation or as a bridge to myocardial recovery. In newborns and small children, the EXCOR Pediatric VAD remains the only reliable option. In some patients ventricular unloading may lead to complete myocardial recovery. There is a strong need for pumps that are fully implantable, suitable for single ventricle physiology, such as the right ventricle.

Role of paediatric assist device in bridge to transplant

Background

While heart transplantation has gained recognition as the gold standard therapy for advanced heart failure, the scarcity of donor organs has become an important concern. The evolution of surgical alternatives such as ventricular assist devices (VADs), allow for recovery of the myocardium and ensure patient survival until heart transplantation becomes possible. This report elaborates the role of VADs as a bridge to heart transplantation in infants and children (≤18 years old) with end-stage heart failure.

Methods

A retrospective review of the medical records of 201 heart transplant recipients between May 1986 and September 2014 identified 78 children [38.8%; mean age 7.2 (7.8±6.0) years old; IQR: 2.6-11.8 years] with advanced heart failure who were supported with a VAD [left VAD (LVAD) =21; biventricular VAD (BVAD) =57] as a bridge to heart transplantation. Fourteen (17.9%) patients were less than 1 year old; 15 (19.2%) children had a cardiac arrest and underwent cardiopulmonary resuscitation, with 7 of these patients also requiring extracorporeal membrane oxygenation (ECMO) support prior to implantation of a VAD. The aetiology of heart failure was primarily cardiomyopathy (dilative, restrictive from endocardial fibrosis, idiopathic or toxic-induced), reported in 56 (71.8%) patients. The VADs employed were primarily Berlin Heart EXCOR^® (n=63), HeartWare (n=13), Berlin Heart INCOR^® (n=1), and Toyobo (n=1).

Results

Mean duration of VAD support was 59 (133.37±191.57) days (range, 1-945 days; IQR: 23-133 days) before a donor heart became available. The primary complication encountered while patients were being bridged to transplant was mediastinal bleeding (7.8%). The main indication for pump exchanges was thrombus formation in the valves. There was no incidence of technical failure of the blood pump or driving system components. Skin infections around the cannulae occurred in 2.5%. Adverse neurological symptoms (thromboembolism 11.1%, cerebral haemorrhage 3.6%) that occurred did not have any permanent neurological sequelae that could be detected on clinical examination in this study. Mean duration of follow-up was 9.4 (10.3±7.6) years (IQR: 3.74-15.14 years). Cumulative survival rates of patients bridged to transplantation with VAD were 93.6%±2.8%, 84.6%±4.1%, 79.1%±4.7%, 63.8%±6.2%, 61.6%±7.1%, and 52.1%±9.3% at 30 days, 1, 5, 10, 15 and 20 years, respectively. There was no statistically significant difference (P=0.79) in survival rates of patients bridged to heart transplantation with VAD compared to those who underwent primary heart transplantation. Post-transplant survival rates stratified according to the type of VAD implanted and number of ventricles supported were not statistically different (P=0.93 and 0.73, respectively). In addition, post-transplant survival rates were not significantly different when age, gender and diagnosis were adjusted for. Furthermore, no statistically significant difference was found when post-transplant survival rates of children who had episodes of rejection were compared to those who did not have episodes of rejection.

Conclusions

The results in this series demonstrate that VADs satisfactorily support paediatric patients with advanced heart failure from a variety of aetiologies until heart transplantation. The data further suggests that patients bridged with VADs have comparable long-term post-transplant survival as those undergoing primary heart transplantation.

Intramyocardial Delivery of Bone Marrow Mononuclear Cells and Mechanical Assist Device Implantation in Patients with End-Stage Cardiomyopathy

In end-stage heart failure, mechanical ventricular assist devices (VAD) are being used as bridge-to-transplantation, as a bridge-to-recovery, or as the definitive therapy. We tested the hypothesis that myocardial implantation of autologous bone marrow mononuclear cells (BMNC) increases the likelihood of successful weaning from left VAD (LVAD) support. Ten patients (aged 14–60 years) with deteriorating heart function underwent LVAD implantation and concomitant implantation of autologous BMNC. Bone marrow was harvested prior to VAD implantation and BMNC were prepared by density centrifugation. Two patients received a pulsatile, extracorporeal LVAD and eight a nonpulsatile implantable device. Between 52 and 164 × 107 BMNC containing between 1 and 12 × 106 CD34+ cells were injected into the LV myocardium. There was one early and one late death. The median time on LVAD support was 243 days (range 24–498 days). Repeated echocardiographic examinations under increased hemodynamic load revealed a significant improvement of LV function in one patient. Three patients underwent heart transplantation, and four patients remain on LVAD support >1 year without evidence of recovery. Only one patient was successfully weaned from LVAD support after 4 months, and LV function has remained stable ever since. In patients with end-stage cardiomyopathy, intramyocardial injection of BMNC at the time of LVAD implantation does not seem to increase the likelihood of successful weaning from VAD support. Other cell-based strategies should be pursued to harness the potential of cell therapy in LVAD patients.

Paediatric mechanical circulatory support with Berlin Heart EXCOR: development and outcome of a 23-year experience

This paper reviews the development and establishment of the Berlin Heart EXCOR® (BHE®) as a paediatric mechanical circulatory support and reports our entire experience with regard to indications, timing of implantation and explantation and outcome. The Berlin group reported the first successful paediatric bridge to transplantation using a pulsatile pneumatic paracorporeal biventricular assist device, the BHE®, in 1990 in an 8-year-old boy with end-stage heart failure and coarctation of the aorta. This experience prompted them to develop miniaturized pump systems for children through the company Berlin Heart Mediproduct GmbH. The development and production of BHE® to support paediatric patients with heart failure then began. Between 1990 and 2013, the BHE® has been implanted in 122 patients (median age 8.64 years, range 3 days to 17 years) with heart failure, who were inotrope-dependent or switched from extracorporeal membrane oxygenation support or had postcardiotomy low-output syndrome. Thirty-five patients were <1 year old (median 125 days). The aetiology of heart failure included cardiomyopathy in 56 (median age 9.14 years), fulminant myocarditis in 17 (median age 8.2 years), end-stage congenital heart disease in 18 (median age 6.4 years), postcardiotomy heart failure (after correction of congenital heart disease) in 28 (median age 9.6 years) and transplant graft failure in 3 (median age 12.5 years). The overall median duration of implantation was 63.6 (range 1-841) days. Fifty-six children eventually underwent orthotopic heart transplantation. Eighteen patients had myocardial recovery and were weaned successfully. They had entirely normal cardiac function after a range of 4-10 years after surgery. At the time of this report, five patients were still on support, with a duration of 354-369 days. Forty-three patients died on the system from loss of peripheral circulatory resistance, multiorgan damage, sepsis or haemorrhagic or thrombotic complications. Re-exploration because of bleeding was necessary in 22 patients. Pump exchange because of thrombus formation in the valves was necessary 35 times. With the introduction of a modified anticoagulation regimen in 2000, the pump exchange rate has decreased. The BHE® can reliably support the circulation at any age for long periods with good results. It is now an established treatment for children with heart failure of any aetiology.

State of the art in paediatric heart transplantation: the Berlin experience

Enormous progress has been made in paediatric heart transplantation since the first unsuccessful effort by Kantrowitz in 1967. Early reports of children undergoing heart transplantation showed alarmingly high perioperative mortality rates of 25-60%, with the diagnosis of congenital heart disease (CHD) representing a particularly high-risk subset compared with cardiomyopathy. Many of these early failures were related to poor patient selection, suboptimal immunosuppression and technical problems. We learned a great deal from these earlier difficulties. Presently, with more refined techniques, better-defined patient selection criteria, excellent graft rejection monitoring and optimal immunosuppression, the ISHLT 2011 registry reported a 10-year survival rate of 60% for patients transplanted for end-stage CHD and >70% for those transplanted for cardiomyopathy. The technical dilemmas in complex CHD were overcome by surgical ingenuity and creativity, innovative solutions and careful surgical planning, adapting the complex recipient anatomy to the normal donor anatomy. The miniaturized Berlin Heart pulsatile ventricular assist devices in children as a bridge to transplantation have revolutionized treatment and become a significant contribution in heart-failure therapy. The intramyocardial electrogram and echocardiographic strain rate imaging have been employed as non-invasive techniques of rejection monitoring. Immunosuppressive drugs have a major impact on the development and progression of cardiac allograft vasculopathy, the main cause of cardiac allograft loss and a leading cause of mortality after the first year post-transplantation. The questions of whether a transplanted heart in a newborn grows to adult size along with the child and whether the dimensional cardiac growth allows adequate function over time have been largely answered in our previous investigations. As more transplanted children reach adulthood, concerns about their life expectancy when they have reached 10 years of life post-transplant are raised, particularly with respect to establishing partnerships and families, their ability to earn a living and the fulfilment of personal life perspectives. Some heart-transplanted patients require retransplantation to remain alive. The disparity between the demand for and supply of donor hearts makes retransplantation an ethical issue. We 'do not refuse' any patient who needs retransplantation. Mechanical circulatory support devices for long-term use are now largely available to accommodate such cases.

Demographics, trends, and outcomes in pediatric acute myocarditis in the United States, 2006 to 2011

BACKGROUND

There is a lack of clear diagnostic and management guidelines for acute myocarditis in the pediatric population. We used a multi-institutional database to characterize demographics, practice variability, and outcomes in this population.

METHODS AND RESULTS

Patients with acute myocarditis (n=514) were identified from April 2006 to March 2011 using the Pediatric Health Information System database, and regional variations in management and outcomes were analyzed. Ninety-seven patients (18.9%) received extracorporeal membrane oxygenation, 22 (4.3%) received ventricular assist device, 21 (4.1%) received heart transplantation, and 37 (7.2%) died. Of the 104 patients who received extracorporeal membrane oxygenation or ventricular assist device, 17 (16.3%) had heart transplantation, 25 (24%) died, and 62 (59.6%) showed recovery of myocardial function. There was a decrease in the use of endomyocardial biopsy (P=0.03) and an increase in the use of magnetic resonance imaging (P<0.01) over the study period. Although the use of medications and procedures varied between different regions, the occurrence of death or heart transplantation showed no significant regional associations. The use of extracorporeal membrane oxygenation (odds ratio, 5.8; 95% confidence interval, 2.9-11.4; P<0.01), ventricular assist device (odds ratio, 8.2; 95% confidence interval, 2.7-24.9; P<0.01), and vasoactive medications (odds ratio, 5.7; 95% confidence interval, 1.2-26.1; P=0.03) was independently associated with death/transplantation.

CONCLUSIONS

There is significant temporal and regional variation in the diagnostic modalities and management used for pediatric myocarditis, which continues to have high morbidity and mortality. Extracorporeal membrane oxygenation, ventricular assist device, and vasoactive medications are independently associated with increased mortality/transplantation.

[Left ventricular assist device in a five-year-old child: a bridge to recovery in a case of viral myocarditis]

INTRODUCTION

Viral myocarditis can lead to heart failure that is refractory to medication. In these cases, a ventricular assist device is a good therapeutic option that can be used as a bridge to transplantation or recovery. We describe the first case in Portugal of recovery with ventricular assistance after severe myocarditis.

CASE REPORT

A five-year-old boy with no previous cardiac disease presented with severe viral myocarditis, refractory to medical treatment, with positive serology for parvovirus B19 and Ebstein-Barr virus. A Berlin Heart Excor(®) was implanted 15 days after diagnosis. A biopsy at the time of implantation showed subendocardial fibrosis. After 40 days of assistance ventricular function recovered and the device was explanted. The patient was discharged from hospital 15 days later.

DISCUSSION

Survival of children with ventricular assistance has improved significantly because of earlier implantation and coagulation monitoring. The presence of subendocardial fibrosis in the context of myocarditis is not a mandatory indication for transplantation.

The evolving approach to paediatric myocarditis: a review of the current literature

Paediatric myocarditis remains challenging from the perspectives of diagnosis and management. Multiple aetiologies exist and the majority of cases appear to be related to viral illnesses. Enteroviruses are believed to be the most common cause, although cases related to adenovirus may be more frequent than suspected. The clinical presentation is extremely varied, ranging from asymptomatic to sudden unexpected death. A high index of suspicion is crucial. There is emerging evidence to support investigations such as serum N-terminal B-type natriuretic peptide levels, as well as cardiac magnetic resonance imaging as adjuncts to the clinical diagnosis. In the future, these may reduce the necessity for invasive methods, such as endomyocardial biopsy, which remain the gold standard. Management generally includes supportive care, consisting of cardiac failure medical management, with the potential for mechanical support and cardiac transplantation. Treatments aimed at immunosuppression remain controversial. The paediatric literature is extremely limited with no conclusive evidence to support or refute these strategies. This article summarises the current literature regarding aetiology, clinical presentation, diagnosis, and management of myocarditis in paediatric patients.

Rescue extracorporeal membrane oxygenation in children with refractory cardiac arrest

We describe our experience with extracorporeal cardiopulmonary resuscitation (CPR) using extracorporeal membrane oxygenation (ECMO) in children with refractory cardiac arrest, and determine predictors for mortality. ECMO support was instituted on 42 children, median age 0.7 years (1 day-17.8 years), median weight 7.05 (range 2.7-80) kg who suffered refractory cardiac arrest (1992-2008). Patients were postcardiotomy (n=27), or had uncorrected congenital heart diseases (n=3), cardiomyopathy (n=3), myocarditis (n=2), respiratory failure (n=3), or had trauma (n=4). Cannulation site was the chest in all except for three neonates who were cannulated through the neck vessels and two children who had femoral cannulation. ECMO was successfully discontinued in 17 patients. Primary cause of mortality was neurological injury. Pre-ECMO CPR duration for survivors against those who died was a mean of 35±1.3 min vs. a mean of 46±4.2 min. Age, weight, sex, anatomic diagnosis, etiology (surgical vs. medical) were not significant predictors of poor outcome. Prolonged CPR and high-dose inotropes are significant predictors of mortality. Rescue ECMO support in children with refractory cardiac arrest can achieve acceptable survival and neurological outcomes.

First pediatric transatlantic air ambulance transportation on a Berlin Heart EXCOR left ventricular assist device as a bridge to transplantation

INTRODUCTION

Mechanical circulatory devices are indicated in patients with refractory cardiac failure as a bridge to recovery or to transplantation. Whenever required, transportation while on mechanical support is a challenge and still limited by technical restrictions or distance.

CASE REPORT

We report the first pediatric case of transatlantic air transportation on a Berlin Heart EXCOR ventricular assist device (Berlin Heart, Berlin, Germany) of a 13-yr-old American female who presented in cardiogenic shock with severe systolic dysfunction while vacationing in France. Rapid hemodynamic deterioration occurred despite maximal medical treatment, and she was supported initially with extracorporeal membrane oxygenation converted to a Berlin Heart EXCOR left ventricular assist device. Long-distance air transportation of the patient was accomplished 3 wks after implantation from Marseille, France, to Denver, Colorado. No adverse hemodynamic effects were encountered during the 13.5-hr flight (8770 km). The patient did not recover sufficient cardiac function and underwent successful orthotopic heart transplantation 3 months after the initial event.

CONCLUSIONS

Our experience suggests that long-distance air transportation of pediatric patients using the Berlin Heart EXCOR mobile unit as a bridge to recovery or transplantation is feasible and appears safe.

Extracorporeal membrane oxygenation for the support of infants, children, and young adults with acute myocarditis: a review of the Extracorporeal Life Support Organization registry

OBJECTIVE

To describe survival outcomes for pediatric patients supported with extracorporeal membrane oxygenation for severe myocarditis and identify risk factors for in-hospital mortality.

DESIGN

Retrospective review of Extracorporeal Life Support Organization registry database.

SETTING

Data reported to Extracorporeal Life Support Organization from 116 extracorporeal membrane oxygenation centers.

PATIENTS

Patients < or = 18 yrs of age supported with extracorporeal membrane oxygenation for myocarditis during 1995 to 2006.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 19,348 reported pediatric extracorporeal membrane oxygenation uses from 1995 to 2006, 260 runs were for 255 patients with a diagnosis of myocarditis (1.3%). Survival to hospital discharge was 61%. Seven patients (3%) underwent heart transplantation and six patients survived to discharge. Of 100 patients not surviving to hospital discharge, extracorporeal membrane oxygenation support was withdrawn in 70 (70%) with multiple organ failure as the indication in 58 (83%) patients. In a multivariable model, female gender (adjusted odds ratio, 2.3, 95% confidence interval, 1.3-4.2), arrhythmia on extracorporeal membrane oxygenation (adjusted odds ratio, 2.7, 95% confidence interval, 1.5-5.1), and renal failure requiring dialysis (adjusted odds ratio, 5.1, 95% confidence interval, 2.3-11.4) were associated with increased odds of in-hospital mortality.

CONCLUSION

Extracorporeal membrane oxygenation is a valuable tool to rescue children with severe cardiorespiratory compromise related to myocarditis. Female gender, arrhythmia on extracorporeal membrane oxygenation, and need for dialysis during extracorporeal membrane oxygenation were associated with increased mortality.

Cost utility evaluation of extracorporeal membrane oxygenation as a bridge to transplant for children with end-stage heart failure due to dilated cardiomyopathy

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) and cardiac transplantation are recognized to be expensive.

METHODS

We performed a cost utility evaluation with a decision model approach, including 75 children with dilated cardiomyopathy. A cohort of patients with end stage heart failure who were offered ECMO bridging was compared with a similar cohort offered only conventional intensive care. Outcome was measured in cost per quality adjusted life year (QALY).

RESULTS

Median follow-up was 4.39 years (interquartile range, 1.83-5.74 years), during which 50 children underwent transplantation, 16 had a period of recovery, and 25 died. ECMO bridging was highly effective (hazard ratio, 0.181; 95% confidence interval, 0.067-0.489; p = 0.001) but exceeded conventional criteria for cost-effectiveness. The reference incremental cost-effectiveness ratio (ICER) was pound65,645 per QALY and pound54,284 per life-year gained. Average life expectancy rose from 6.78 to 9.79 years and costs from pound146,398 to pound309,599 per patient with ECMO bridging. The ICER was sensitive to ECMO cost, the long-term transplant survival rate, and quality of life in transplant recipients.

CONCLUSIONS

ECMO bridging is effective but expensive. The eligible target population is small, nationally, positively influencing affordability. We strongly support our national policy of mechanical bridge to transplant for suitable children in end stage heart failure. Cost effectiveness could be optimized by: 1) increased availability of organ donors, 2) reduction in mechanical support costs possibly by alternate devices and 3) inclusion of patients most likely to benefit.

Neonatal extra-corporeal life support: indications and limitations

Cardiac extra-corporeal life support is used more frequently in the current era of complex, high-risk neonatal heart surgery. Although outcome for neonates with complex heart disease has improved in the last decade, thanks to advances in surgery and intensive care, survival in the subset that require extra-corporeal support remains unchanged at below 40%. Neonatal cardiac extra-corporeal support is a technically challenging therapy that is applied in a range of contexts including: post-operative low cardiac output syndrome, cardiac arrest, high-risk interventional catheterisation or as a bridge to recovery from dysrhythmia and myocarditis. Extra-corporeal life support has increased in particular for neonates with single ventricle disease in the last 5 years, mainly achieving similar results to biventricular patients. Further research is required in order to determine the optimal methods for patient selection and to establish important predictors of outcome including the longterm neurological development of survivors.

Mechanical circulatory support for the pediatric patient

In adult patients, mechanical circulatory support (MCS) devices are part of the standard of care for heart failure. There are several options available that clinicians may use to provide support for their patients and thus the choice of devices can be tailored to their individual needs. Unfortunately, this is not the case for pediatric patients with heart failure, where the options for MCS modalities are far more limited because of size constraints and regulatory hurdles. Furthermore, the pathophysiology of heart failure in children is not identical to that of adults; thus, the device selection and configuration require different considerations. Management of pediatric patients on MCS requires a highly specialized team of pediatric professionals. The nurse caring for a child on MCS is an active participant in all aspects of the patient's care and must have an in-depth understanding of the patient's underlying physiology, the circulatory physiology of the MCS system, the reason for mechanical support, and the goal of support.

Ventricular assist devices in children: current achievements and future perspectives

Mechanical circulatory support systems for the treatment of acute and chronic heart failure are now available for use in several clinical situations and are designed for different indications and support times. In children, particularly in small infants, extracorporeal membrane oxygenation and centrifugal pumps have been most widely used in the past. These systems are preferred for support after cardiac operations and for use in patients who have concomitant respiratory failure, but they are suitable for short-term application only and intensive care is obligatory. VADs are designed for long-term application and allow patients to be discharged home. Pneumatic pulsatile VADs have been available in pediatric sizes since 1992. Currently at our institution, 74 children have been supported with pediatric extracorporeal VADs for up to 14 months. In the past five yr, a notable rise in survival has been achieved by improvements in pump design and pre- and post-operative management. We have been able to discharge 78% of the infants under one yr old. In this review, our current VAD experience in children will be presented in the light of improvements in decision-making, device technology, and implantation techniques, and in coagulation monitoring and anticoagulation. Additionally, new developments in the field of pediatric assist devices will be presented.

Extracorporeal Membrane Oxygenation for Perioperative Cardiac Support in Children I: Experience at the Deutsches Herzzentrum Berlin (1987–2005)

We report our experience in pediatric patients supported by extracorporeal membrane oxygenation (ECMO) for perioperative circulatory failure from January 1987 to June 2005. Pediatric patients (n = 110) who had ECMO support for congenital heart defects, myocarditis, and cardiomyopathy (age range, newborn to 18 years; weight range, 2.3-69 kg) were included and divided into three groups based on timing of ECMO support. EMCO support was used preoperatively in 21 patients (19.1%) (mean age, 4 years +/- 8 months; mean weight, 23.7 +/- 8.9 kg). Duration of ECMO support was 8.3 +/- 7 days. Fifty-six patients (56.56%) (mean age, 5.11 +/- 5 years; mean weight, 15.7 +/- 6.9 kg) had intraoperative ECMO support for myocardial insufficiency, low output syndrome, right ventricular failure, left ventricular failure, malignant arrhythmia, pulmonary hypertension, and repeated resuscitation. Mean duration of ECMO support was 4.98 +/- 1 days. Postoperative ECMO support was used in 29 patients (mean age, 7.5 +/- 1 years; mean weight, 23.4 +/- 6.4 kg). Mean duration of ECMO was 4.6 +/- 1 days. Mean postoperative day of ECMO institution was 40.4 +/- 2 days. Our experience shows that ECMO support can be offered perioperatively to any patient with potentially reversible pulmonary, cardiac, or cardiopulmonary failure, excluding those whose outcome is inevitable.