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Bhaskar P, Davila S, Hoskote A, Thiagarajan R. Use of ECMO for Cardiogenic Shock in Pediatric Population. J Clin Med 2021; 10:jcm10081573. [PMID: 33917910 PMCID: PMC8068254 DOI: 10.3390/jcm10081573] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/18/2021] [Accepted: 03/03/2021] [Indexed: 01/11/2023] Open
Abstract
In children with severe advanced heart failure where medical management has failed, mechanical circulatory support in the form of veno-arterial extracorporeal membrane oxygenation (VA ECMO) or ventricular assist device represents life-sustaining therapy. This review provides an overview of VA ECMO used for cardiovascular support including medical and surgical heart disease. Indications, contraindications, and outcomes of VA ECMO in the pediatric population are discussed.VA ECMO provides biventricular and respiratory support and can be deployed in rapid fashion to rescue patient with failing physiology. There have been advances in conduct and technologic aspects of VA ECMO, but survival outcomes have not improved. Stringent selection and optimal timing of deployment are critical to improve mortality and morbidity of the patients supported with VA ECMO.
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Affiliation(s)
- Priya Bhaskar
- Division of Pediatric Critical Care, UT Southwestern Medical Center, Children’s Medical Center, Dallas, TX 75235, USA; (P.B.); (S.D.)
| | - Samuel Davila
- Division of Pediatric Critical Care, UT Southwestern Medical Center, Children’s Medical Center, Dallas, TX 75235, USA; (P.B.); (S.D.)
| | - Aparna Hoskote
- Cardiac Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N 3JH, UK;
| | - Ravi Thiagarajan
- Department of Cardiology, Division of Cardiovascular Critical Care, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Correspondence:
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Comentale G, Giordano R, Pilato E, D'Amore A, Romano R, Simeone S, Browning R, Palma G, Iannelli G. "The heart supporters": systematic review for ventricle assist devices in congenital heart surgery. Heart Fail Rev 2019; 25:1027-1035. [PMID: 31734755 DOI: 10.1007/s10741-019-09892-0] [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] [Indexed: 11/25/2022]
Abstract
Ventricular assist device (VAD) implantation is a widely used procedure in children with cardiac failure refractory to medical therapy as a long-term bridge to recovery or transplant. This strategy has proved to be of an enormous advantage in the cure of these children. The aim of this review is to evaluate the current strategies used for clinical monitoring of paediatric patients with a VAD, focusing on the management of several aspects such as anticoagulant and antiplatelet therapy, haemorrhagic and thrombotic complications, as well as the effects that VADs have on the exposure, effectiveness and the safety of drugs. The sources used for this research are MEDLINE, PubMed and Cochrane Library. The use of key words such as "paediatric ventricular assist device", "clinical management", "anticoagulant therapy" and "infections" retrieved 146 papers. With the application of the inclusion criteria, 42 articles have been selected, but following further analysis, only 21 were eligible. The post-implant process is still complicated due to the lack of guidelines regarding clinical management and for the frequent occurrence of adverse events including bleeding, infection and thromboembolic episodes. From these findings, we can highlight the importance of establishing a suitable antithrombotic therapy, as well as ensuring that the prevention and treatment of infection are paramount during the management of these patients. The clinical management of VAD paediatric children is complex and challenging. At the moment, there are no guidelines regarding strategies to adopt, but from the analysed surveys, it has been possible to highlight a relative coherence between adopted therapies in different centres worldwide.
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Affiliation(s)
- Giuseppe Comentale
- Division of Cardiac Surgery, University of Napoli "Federico II", Sergio Pansini n°5, 80131, Napoli, Italy.
| | - Raffaele Giordano
- Division of Cardiac Surgery, University of Napoli "Federico II", Sergio Pansini n°5, 80131, Napoli, Italy
| | - Emanuele Pilato
- Division of Cardiac Surgery, University of Napoli "Federico II", Sergio Pansini n°5, 80131, Napoli, Italy
| | - Anna D'Amore
- Division of Cardiac Surgery, University of Napoli "Federico II", Sergio Pansini n°5, 80131, Napoli, Italy
| | - Roberta Romano
- Division of Pediatrics, University of Napoli "Federico II", Sergio Pansini n°5, 80131, Napoli, Italy
| | - Silvio Simeone
- Division of Cardiac Surgery, University of Napoli "Federico II", Sergio Pansini n°5, 80131, Napoli, Italy
| | - Rosie Browning
- Division of Cardiovascular Perfusion, The Royal Brompton, London, UK
| | - Gaetano Palma
- Division of Cardiac Surgery, University of Napoli "Federico II", Sergio Pansini n°5, 80131, Napoli, Italy
| | - Gabriele Iannelli
- Division of Cardiac Surgery, University of Napoli "Federico II", Sergio Pansini n°5, 80131, Napoli, Italy
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Mechanical circulatory support using modified TandemHeart ventricular assist device in neonates with CHD. Cardiol Young 2018; 28:1361-1362. [PMID: 30152304 DOI: 10.1017/s1047951118001245] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
TandemHeart, an adult ventricular assist device, is also being used in children for mechanical circulatory support. In this case series, we describe our experience using TandemHeart ventricular assist device with a modified circuit to provide mechanical circulatory support in three neonates for multiple indications. TandemHeart ventricular assist device with a modified circuit can be used successfully to provide extracorporeal support to neonates with complex CHD.
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Friedland-Little JM, Hong BJ, Gossett JG, Deshpande SR, Law S, Hollifield KA, Cantor RS, Koehl D, Kindel SJ, Turrentine MW, Davies RR. Changes in renal function after left ventricular assist device placement in pediatric patients: A Pedimacs analysis. J Heart Lung Transplant 2018; 37:1218-1225. [PMID: 30293616 DOI: 10.1016/j.healun.2018.06.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 04/21/2018] [Accepted: 06/21/2018] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Renal dysfunction (RD) is prevalent among pediatric patients with advanced heart failure. Data are limited regarding changes in renal function after left ventricular assist device (LVAD) placement in this population. METHODS Pediatric LVAD recipients enrolled in the Pediatric Interagency Registry for Mechanical Circulatory Support (Pedimacs) between September 19, 2012 and June 30, 2016 were included. Longitudinal changes in renal function were analyzed for the entire cohort as well as subgroups stratified by patient and device characteristics. Logistic regression was used to attempt to identify factors associated with lack of improvement in renal function after LVAD placement. Post-LVAD outcomes were assessed using the Kaplan‒Meier method. RESULTS Data from 247 patients from 39 centers were analyzed. Baseline RD (estimated glomerular filtration rate [eGFR] <90 ml/min/1.73 m2) was present in 150 (61%) patients. Overall, eGFR improved post-LVAD, peaking at 1 month post-implant. There was an inverse relationship between baseline eGFR and the degree of improvement at 1 month. Degree of improvement in eGFR at 1 month was not impacted by device type, age, Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile, or diagnosis. Failure to normalize renal function at 1 week was correlated with persistent RD at 1 month. Post-implant outcomes did not differ among patients stratified by pre-implant renal function. CONCLUSIONS Renal function improves post-LVAD placement in pediatric patients regardless of age, diagnosis, illness severity, or device type, with improvement most pronounced in patients with baseline RD. Identifying patients with irreversible renal dysfunction before LVAD placement remains difficult. Pre-LVAD renal function does not appear to impact survival to transplant.
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Affiliation(s)
| | - Borah J Hong
- Heart Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - Jeffrey G Gossett
- Division of Pediatric Cardiology, University of California at San Francisco, San Francisco, California, USA
| | - Shriprasad R Deshpande
- Division of Pediatric Cardiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sabrina Law
- Division of Pediatric Cardiology, New York Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, New York, USA
| | - Kathryn A Hollifield
- Kirklin Institute for Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ryan S Cantor
- Kirklin Institute for Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Devin Koehl
- Kirklin Institute for Surgical Outcomes, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Steven J Kindel
- Division of Pediatric Cardiology, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Mark W Turrentine
- Division of Cardiothoracic Surgery, Riley Children's Hospital, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ryan R Davies
- Department of Cardiovascular and Thoracic Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
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Abstract
Heart transplantation in pediatric patients generally arises as a treatment option of last resort, that is, the indication is for patients with heart failure of various etiologies, with potential or actual end-organ dysfunction, in whom there are no reasonable, long-term options for life-prolonging therapy. The concept of heart failure is complex in a pediatric population, particularly those with congenital heart disease. While heart failure may refer simply to systolic dysfunction leading to low cardiac output, it can also encompass: diastolic dysfunction in restrictive cardiomyopathy; single ventricle physiology without an option for stable palliation. A good candidate should have a predicted life expectancy less than the median lifetime of a transplanted heart. Significant improvement in survival has been observed over time with 1- and 5-year survival approximately 90% and 80% in the contemporary era.
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Affiliation(s)
- Thomas D Ryan
- Division of Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave-MLC 2003, Cincinnati, Ohio 45229
| | - Clifford Chin
- Division of Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave-MLC 2003, Cincinnati, Ohio 45229.
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