Outcomes and Trends of Ventricular Assist Device Selection in Children with End-Stage Heart Failure

Trends in Contemporary Use of Ventricular Assist Devices in Children Awaiting Heart Transplantation and Their Outcomes by Race/Ethnicity

This retrospective study included children aged ≤18 years who had durable ventricular assist devices (VADs) as a bridge to transplantation from the United Network Organ Sharing (UNOS) database between 2011 and 2020. We evaluated 90 day waitlist mortality and 1 year posttransplant mortality after VAD implantation in children stratified by race/ethnicity: Black, White, and Others. The VAD was used in a higher proportion of Black children listed for heart transplantation (HT) (26%) versus Other (25%) versus White (22%); p < 0.01. Black children had Medicaid health insurance coverage (67%) predominantly at the time of listing for HT. There was no significant overall difference in waitlist survival among the three groups supported with VAD at the time of listing (log-rank p = 0.4). On the other hand, the 90 day waitlist mortality after the VAD implantation at listing and while listed was the lowest among Black (6%) compared with White (13%) and Other (14%) ( p < 0.01). The multivariate regression analysis showed that Other race (hazard ratio [HR], 2.29; p < 0.01), Black race (HR, 2.13; p < 0.01), use of mechanical ventilation (HR, 1.72; p = 0.01), and Medicaid insurance (HR, 1.54; p = 0.04) were independently associated with increased 1 year posttransplant mortality. In conclusion, Black children had more access to durable VAD support than White children. The 90 day waitlist mortality was significantly lower in Black children compared with White and Other after VAD implantation. However, Black and Other racial/ethnic children with VAD at transplant had higher 1 year posttransplant mortality than White children. Future studies to elucidate the reasons for these disparities are needed.

Surgical strategies for the management of end-stage heart failure in infants and children: A 15-year experience with a patient-tailored approach

End‐stage heart failure (ESHF) in pediatric age is an ongoing challenge. Heart transplantation is the final option, but its long‐term outcomes are still suboptimal in children. An alternative patient‐tailored surgical protocol to manage ESHF in children is described. Retrospective, single‐center analysis of pediatric patients admitted to our institution between April 2004 and February 2021 for ESHF. Our current protocol is as follows: (a) Patients <1 year with isolated left ventricular dysfunction due to dilated cardiomyopathy underwent pulmonary artery banding (PAB). (b) Patients <10 years and <20 kg, who did not meet previous criteria were managed with Berlin Heart EXCOR. (c) Patients >10 years or >20 kg, underwent placement of intracorporeal Heartware. Primary outcomes were survival, transplant incidence, and postoperative adverse events. A total of 24 patients (mean age 5.3 ± 5.9 years) underwent 26 procedures: PAB in 6 patients, Berlin Heart in 11, and Heartware in 7. Two patients shifted from PAB to Berlin Heart. Overall survival at 1‐year follow‐up and 5‐year follow‐up was 78.7% (95%CI = 62%‐95.4%) and 74.1% (95%CI = 56.1%‐92.1%), respectively. Berlin Heart was adopted in higher‐risk settings showing inferior outcomes, whereas a PAB enabled 67% of patients to avoid transplantation, with no mortality. An integrated, patient‐tailored surgical strategy, comprehensive of PAB and different types of ventricular assist devices, can provide satisfactory medium‐term results for bridging to transplant or recovery. The early postoperative period is critical and requires strict clinical vigilance. Selected infants can benefit from PAB that has demonstrated to be a safe bridge to recovery.

Caring for Pediatric Heart Failure Patients With Long-Term Mechanical Circulatory Support

Pediatric cardiac failure is a significant problem that may be caused by cardiomyopathy, myocarditis, or congenital defects that cannot be surgically repaired. Long-term mechanical circulatory support (LTMCS) devices provide hemodynamic support for patients in heart failure as a bridge to heart transplant and, sometimes, cardiac recovery or destination therapy. Critical care nurses must have a comprehensive understanding of LTMCS device function and keen assessment skills to detect signs of impaired perfusion and device failure. Nurses should anticipate postoperative interventions, prevent adverse events, and be prepared to respond during emergencies. Patient care should be family centered and nurses must strive to maximize patients' quality of life throughout device implantation. This article provides a basic guide to caring for pediatric patients receiving LTMCS, including specific information regarding 4 devices that are often used for pediatric heart failure: Berlin Heart EXCOR, SynCardia Total Artificial Heart, HeartWare HVAD, and HeartMate II.

An overview of mechanical circulatory support in single-ventricle patients

The population of people with a single-ventricle is continually increasing due to improvements across the spectrum of medical care. Unfortunately, a proportion of these patients will develop heart failure. Often, for these patients, mechanical circulatory support (MCS) represents the only available treatment option. While single-ventricle patients currently represent a small proportion of the total number of patients who receive MCS, as the single-ventricle patient population increases, this number will increase as well. Outcomes for these complex single-ventricle patients who require MCS has begun to be evaluated. When considering the entire population, survival to hospital discharge is 30-50%, though this must be considered with the significant heterogeneity of the single-ventricle patient population. Patients with a single-ventricle have unique anatomy, mechanisms of failure, indications for MCS and the type of support utilized. This has made the interpretation and the generalizability of the limited available data difficult. It is likely that some subsets will have a significantly worse prognosis and others a better one. Unfortunately, with these limited data, indications of a favorable or poor outcome have not yet been elucidated. Though currently, a database has been constructed to address this issue. While the outcomes for these complex patients is unclear, at least in some situations, they are poor. However, significant advances may provide improvements going forward, including new devices, computer simulations and 3D printed models. The most important factor, however, will be the increased experience gained by the heart failure team to improve patient selection, timing, device and configuration selection and operative approach.