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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: 23] [Impact Index Per Article: 11.5] [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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Ragusa R, Di Molfetta A, Amodeo A, Trivella MG, Caselli C. Pathophysiology and molecular signalling in pediatric heart failure and VAD therapy. Clin Chim Acta 2020; 510:751-759. [PMID: 32949569 DOI: 10.1016/j.cca.2020.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 09/04/2020] [Accepted: 09/09/2020] [Indexed: 02/06/2023]
Abstract
Heart Failure (HF) is a progressive clinical syndrome characterized by molecular and structural abnormalities that result in impaired ventricular filling and a reduced blood ejection. In pediatric patients, HF represents an important cause of morbidity and mortality, but underlying cause, presentation and disease course remains unclear in many cases. It is evident that a child is not a "small adult" and findings are not comparable. The adoption of a standardized clinical and surgical tools as well as increased biomolecular research and therapeutic trials targeting pediatric patients with HF would greatly improve the management of this special class of patients. This review examines the most current information about the pathophysiology and molecular mechanisms related to HF in children to identify gaps in our knowledge base to further improve clinical care and outcomes.
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Affiliation(s)
- Rosetta Ragusa
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy; Institute of Clinical Physiology, CNR, Pisa, Italy
| | - Arianna Di Molfetta
- Department of Cardiothoracic Surgery, Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Antonio Amodeo
- Department of Cardiothoracic Surgery, Ospedale Pediatrico Bambino Gesù, Rome, Italy
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Philip J, Machado D, Shih R, Shenoy A, Ebraheem M, Sullivan K, Vyas H, Gupta D, Bleiweis M. Myocardial recovery following pulsatile biventricular assist device support in infants: Report of 2 cases. JTCVS Tech 2020; 5:89-92. [PMID: 34318118 PMCID: PMC8299981 DOI: 10.1016/j.xjtc.2020.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 03/30/2020] [Accepted: 04/07/2020] [Indexed: 11/28/2022] Open
Affiliation(s)
- Joseph Philip
- Congenital Heart Center, College of Medicine, University of Florida, Gainesville, Fla
| | - Desiree Machado
- Congenital Heart Center, College of Medicine, University of Florida, Gainesville, Fla
| | - Renata Shih
- Congenital Heart Center, College of Medicine, University of Florida, Gainesville, Fla
| | - Archana Shenoy
- Department of Pathology, College of Medicine, University of Florida, Gainesville, Fla
| | - Mohammed Ebraheem
- Congenital Heart Center, College of Medicine, University of Florida, Gainesville, Fla
| | - Kevin Sullivan
- Congenital Heart Center, College of Medicine, University of Florida, Gainesville, Fla.,Department of Anesthesia, College of Medicine, University of Florida, Gainesville, Fla
| | - Himesh Vyas
- Congenital Heart Center, College of Medicine, University of Florida, Gainesville, Fla
| | - Dipankar Gupta
- Congenital Heart Center, College of Medicine, University of Florida, Gainesville, Fla
| | - Mark Bleiweis
- Congenital Heart Center, College of Medicine, University of Florida, Gainesville, Fla.,Division of Cardiothoracic Surgery, College of Medicine, University of Florida, Gainesville, Fla
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Tominaga Y, Ueno T, Kido T, Kanaya T, Narita J, Ishida H, Toda K, Kuratani T, Sawa Y. Bridge to recovery with Berlin Heart EXCOR in children <10 kg with dilated cardiomyopathy: a histological analysis. Eur J Cardiothorac Surg 2020; 58:253-260. [DOI: 10.1093/ejcts/ezaa033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 01/07/2020] [Accepted: 01/09/2020] [Indexed: 11/13/2022] Open
Abstract
Abstract
OBJECTIVES
This study aimed to identify the histological characteristics associated with bridge to recovery using Berlin Heart EXCOR® (BHE) in paediatric patients <10 kg with dilated cardiomyopathy.
METHODS
Of the 10 consecutive patients <10 kg with dilated cardiomyopathy who underwent BHE implantation between 2013 and 2018, 4 patients showed improvement in left ventricular (LV) function, resulting in successful BHE explantation (recovery group). The remaining 6 patients showed persistent LV dysfunction and underwent heart transplantation (non-recovery group). The following variables were compared between the 2 groups: (i) histological findings in LV myocardium obtained at BHE implantation and (ii) LV function after BHE implantation assessed with echocardiography and cardiac catheterization.
RESULTS
The degree of myocardial fibrosis was significantly lower, and the capillary vascular density was significantly higher in the recovery group than in the non-recovery group [16% (standard deviation 5.9%) vs 28% (5.9%), P = 0.021, and 65 (11) vs 43 (18) units/high-power field, P = 0.037, respectively]. The changes during 3 months after BHE implantation in LV diastolic dimension (z-score) and ejection fraction were significantly greater in the recovery group than in the non-recovery group [−9.6 (3.5) vs −3.6 (4.5), P = 0.045, and 36% (13%) vs 13% (13%), P = 0.032, respectively].
CONCLUSIONS
In paediatric patients <10 kg with dilated cardiomyopathy, bridge to recovery with BHE implantation was achieved in patients with less injured LV myocardial histology at BHE implantation.
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Affiliation(s)
- Yuji Tominaga
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Takayoshi Ueno
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Takashi Kido
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Tomomitsu Kanaya
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Jun Narita
- Department of Pediatrics, Pediatric Cardiology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hidekazu Ishida
- Department of Pediatrics, Pediatric Cardiology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Koichi Toda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Toru Kuratani
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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Simon MA, Bachman TN, Watson J, Baldwin JT, Wagner WR, Borovetz HS. Current and Future Considerations in the Use of Mechanical Circulatory Support Devices: An Update, 2008–2018. Annu Rev Biomed Eng 2019; 21:33-60. [DOI: 10.1146/annurev-bioeng-062117-121120] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Our review in the 2008 volume of this journal detailed the use of mechanical circulatory support (MCS) for treatment of heart failure (HF). MCS initially utilized bladder-based blood pumps generating pulsatile flow; these pulsatile flow pumps have been supplanted by rotary blood pumps, in which cardiac support is generated via the high-speed rotation of computationally designed blading. Different rotary pump designs have been evaluated for their safety, performance, and efficacy in clinical trials both in the United States and internationally. The reduced size of the rotary pump designs has prompted research and development toward the design of MCS suitable for infants and children. The past decade has witnessed efforts focused on tissue engineering–based therapies for the treatment of HF. This review explores the current state and future opportunities of cardiac support therapies within our larger understanding of the treatment options for HF.
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Affiliation(s)
- Marc A. Simon
- Department of Medicine, Vascular Medicine Institute, and Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA
| | - Timothy N. Bachman
- Department of Medicine, Vascular Medicine Institute, and Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA
| | - John Watson
- Department of Bioengineering, University of California, San Diego, La Jolla, California 92093, USA
| | - J. Timothy Baldwin
- National Heart, Blood, and Lung Institute, Bethesda, Maryland 20892, USA
| | - William R. Wagner
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA
- Department of Chemical and Petroleum Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA
| | - Harvey S. Borovetz
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA
- Department of Chemical and Petroleum Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA
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Miera O, Germann M, Cho MY, Photiadis J, Delmo Walter EM, Hetzer R, Berger F, Schmitt KRL. Bridge to recovery in children on ventricular assist devices-protocol, predictors of recovery, and long-term follow-up. J Heart Lung Transplant 2018; 37:1459-1466. [PMID: 30292432 DOI: 10.1016/j.healun.2018.08.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 08/03/2018] [Accepted: 08/04/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The majority of children supported with ventricular assist devices (VADs) are bridged to heart transplantation. Although bridge to recovery has been reported, low recovery patient numbers has precluded systematic analysis. The aim of this study was to delineate recovery rates and predictors of recovery and to report on long-term follow-up after VAD explantation in children. METHODS Children bridged to recovery at our institution from January 1990 to May 2016 were compared with a non-recovery cohort. Clinical and echocardiographic data before and at pump stoppages and after VAD explantation were analyzed. Kaplan‒Meier estimates of event-free survival, defined as freedom from death or transplantation after VAD removal, were determined. RESULTS One hundred forty-nine children (median age 5.8 years) were identified. Of these, 65.2% had cardiomyopathy, 9.4% had myocarditis, and 24.8% had congenital heart disease. The overall recovery rate was 14.2%, and was 7.1% in patients with dilated cardiomyopathy. Predictors of recovery were age <2 years (recovery rate 27.8%, odds ratio [OR] 5.64, 95% confidence interval [CI] 2.0 to 16.6) and diagnosis of myocarditis (rate 57.1%; OR 17.56, 95% CI 4.6 to 67.4). After a median follow-up of 10.8 years, 15 patients (83.3%) were in Functional Class I and 3 (16.7%) in were in Class II. Mean left ventricular ejection fraction was 53% (range 28% to 64%). Ten- and 15-year event-free survival rates were both 84.1 ± 8.4%. CONCLUSIONS Children <2 years of age and those diagnosed with myocarditis have the highest probability of recovery. Long-term survival after weaning from the VAD was better than after heart transplantation, as demonstrated in the excellent long-term stability of ejection fraction and functional class.
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Affiliation(s)
- Oliver Miera
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany.
| | - Matthias Germann
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - My Y Cho
- Department of Surgery for Congenital Heart Disease/Pediatric Cardiac Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Joachim Photiadis
- Department of Surgery for Congenital Heart Disease/Pediatric Cardiac Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Eva M Delmo Walter
- Department of Cardiothoracic, Transplantation and Vascular Surgery/Pediatric and Congenital Heart Disease Surgery, Hannover Medical School, Hannover, Germany; Cardio Centrum Berlin, Berlin, Germany
| | | | - Felix Berger
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany; German Centre for Cardiovascular Research, Partner Site Berlin, Berlin, Germany; Charité‒Universitätsmedizin Berlin, Berlin, Germany
| | - Katharina R L Schmitt
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany; German Centre for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
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Medina E, Sucharov CC, Nelson P, Miyamoto SD, Stauffer BL. Molecular Changes in Children with Heart Failure Undergoing Left Ventricular Assist Device Therapy. J Pediatr 2017; 182:184-189.e1. [PMID: 27908653 PMCID: PMC5328921 DOI: 10.1016/j.jpeds.2016.11.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 10/03/2016] [Accepted: 11/02/2016] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To determine whether left ventricular assist device (LVAD) treatment in children with heart failure would result in the modification of molecular pathways involved in heart failure pathophysiology. STUDY DESIGN Forty-seven explanted hearts from children were studied (16 nonfailing control, 20 failing, and 11 failing post-LVAD implantation [F-LVAD]). Protein expression and phosphorylation states were determined by receptor binding assays and Western blots. mRNA expression was measured with real-time quantitative polymerase chain reaction. To evaluate for interactions and identify correlations, 2-way ANOVA and regression analysis were performed. RESULTS Treatment with LVAD resulted in recovery of total β-adrenergic receptor expression and β1-adrenergic receptor (β1-AR) in failing hearts to normal levels (β-adrenergic receptor expression : 67.2 ± 11.5 fmol/mg failing vs 99.5 ± 27.7 fmol/mg nonfailing, 104 ± 38.7 fmol/mg F-LVAD, P ≤ .01; β1-AR: 52.2 ± 10.3 fmol/mg failing vs 83.0 ± 23 fmol/mg non-failing, 76.5 ± 32.1 fmol/mg F-LVAD P ≤ .03). The high levels of G protein-coupled receptor kinase-2 were returned to nonfailing levels after LVAD treatment (5.6 ± 9.0 failing vs 1.0 ± 0.493 nonfailing, 1.0 ± 1.3 F-LVAD). Interestingly, β2-adrenergic receptor expression was significantly greater in F-LVAD (27.5 ± 12; P < .005) hearts compared with nonfailing (16.4 ± 6.1) and failing (15.1 ± 4.2) hearts. Phospholamban phosphorylation at serine 16 was significantly greater in F-LVAD (7.7 ± 11.7) hearts compared with nonfailing (1.0 ± 1.2, P = .02) and failing (0.8 ± 1.0, P = .01) hearts. Also, atrial natriuretic factor (0.6 ± 0.8) and brain natriuretic peptide (0.1 ± 0.1) expression in F-LVAD was significantly lower compared with failing hearts (2.8 ± 3.6, P = .01 and 0.6 ± 0.7, P = .02). CONCLUSION LVAD treatment in children with heart failure results in reversal of several pathologic myocellular processes, and G protein-coupled receptor kinase-2 may regulate β1-AR but not β2-adrenergic receptor expression in children with heart failure.
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Affiliation(s)
- Elizabeth Medina
- Division of Cardiology, Department of Medicine, University of Colorado Denver, Aurora, CO
| | - Carmen C. Sucharov
- Division of Cardiology, Department of Medicine, University of Colorado Denver, Aurora, CO
| | - Penny Nelson
- Division of Cardiology, Department of Medicine, University of Colorado Denver, Aurora, CO
| | - Shelley D. Miyamoto
- Department of Pediatrics, University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora, CO
| | - Brian L. Stauffer
- Division of Cardiology, Department of Medicine, University of Colorado Denver, Aurora, CO
- Division of Cardiology, Department of Medicine, Denver Health and Hospital Authority, Denver, CO
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Lara DA, Jeewa A, Elias BA, McCullum EO, Denfield SW, Dreyer WJ, Adachi I. Titanium Plug Closure after HeartWare Ventricular Assist Device Explantation in a 15-Year-Old Girl: First U.S. Experience. Tex Heart Inst J 2017; 44:66-69. [PMID: 28265217 DOI: 10.14503/thij-15-5628] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
We describe the case of a teenage girl with anthracycline-induced cardiomyopathy who received a HeartWare ventricular assist device and underwent successful device explantation after cardiac recovery. During device support, the patient's cardiac function returned to normal. Twelve months after implantation, we explanted the device via repeat median sternotomy. To close the hole in the left ventricular apex and preserve the sewing ring in case future device support is needed, we used a German-manufactured titanium plug, developed specifically for this purpose. To our knowledge, this is the first use of this plug in the United States. The patient recovered uneventfully and was discharged from the hospital on postoperative day 11. Left ventricular biopsy specimens at explantation revealed the resolution of previous degenerative sarcomeric changes. Our patient did well clinically; however, recurrent late anthracycline cardiotoxicity might subsequently cause her cardiac function to deteriorate. In this event, our use of the titanium plug to preserve the left ventricular sewing ring would enable easier device replacement than would other explantation options.
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Abstract
The field of pediatric mechanical circulatory support has undergone a significant evolution with the advent of devices designed for children and the implementation of new strategies for deployment. With the ongoing shortage of organs the demand for new devices specifically designed for children will only increase. This review discusses the evolution of mechanical circulatory support, available devices, and the implementation of new strategies for their deployment.
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Affiliation(s)
- Iki Adachi
- Baylor College of Medicine, Houston, TX. 6621, Fannin st. Houston, Tx, 77030, USA.
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Cohen DG, Thomas JD, Freed BH, Rich JD, Sauer AJ. Echocardiography and Continuous-Flow Left Ventricular Assist Devices. JACC-HEART FAILURE 2015; 3:554-564. [DOI: 10.1016/j.jchf.2015.03.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 02/13/2015] [Accepted: 03/06/2015] [Indexed: 10/23/2022]
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Weia BC, Adachi I, Jacot JG. Clinical and Molecular Comparison of Pediatric and Adult Reverse Remodeling With Ventricular Assist Devices. Artif Organs 2015; 39:691-700. [DOI: 10.1111/aor.12451] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
| | - Iki Adachi
- Congenital Heart Surgery; Texas Children's Hospital; Houston TX USA
- Michael E. DeBakey Department of Surgery; Baylor College of Medicine; Texas Medical Center; Houston TX USA
| | - Jeffrey G. Jacot
- Department of Bioengineering; Rice University; Houston TX USA
- Congenital Heart Surgery; Texas Children's Hospital; Houston TX USA
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12
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Miller JR, Lancaster TS, Eghtesady P. Current approaches to device implantation in pediatric and congenital heart disease patients. Expert Rev Cardiovasc Ther 2015; 13:417-27. [PMID: 25732410 PMCID: PMC4813307 DOI: 10.1586/14779072.2015.1021786] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The pediatric ventricular assist device (VAD) has recently shown substantial improvements in survival as a bridge to heart transplant for patients with end-stage heart failure. Since that time, its use has become much more frequent. With increasing utilization, additional questions have arisen including patient selection, timing of VAD implantation and device selection. These challenges are amplified by the uniqueness of each patient, the recent abundance of literature surrounding VAD use as well as the technological advancements in the devices themselves. Ideal strategies for device placement must be sought, for not only improved patient care, but also for optimal resource utilization. Here, we review the most relevant literature to highlight some of the challenges facing the heart failure specialist, and any physician, who will care for a child with a VAD.
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Affiliation(s)
- Jacob R Miller
- Pediatric Cardiothoracic Surgery, Washington University School of Medicine, St. Louis Children’s Hospital, St. Louis, MO
| | - Timothy S Lancaster
- Pediatric Cardiothoracic Surgery, Washington University School of Medicine, St. Louis Children’s Hospital, St. Louis, MO
| | - Pirooz Eghtesady
- Pediatric Cardiothoracic Surgery, Washington University School of Medicine, St. Louis Children’s Hospital, St. Louis, MO
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13
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Jabbar AA, Franklin WJ, Simpson L, Civitello AB, Delgado RM, Frazier OH. Improved systemic saturation after ventricular assist device implantation in a patient with decompensated dextro-transposition of the great arteries after the Fontan procedure. Tex Heart Inst J 2015; 42:40-3. [PMID: 25873797 DOI: 10.14503/thij-13-3374] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
We report the successful implantation of a HeartMate II left ventricular assist device after a failed Fontan procedure in a patient with dextro-transposition of the great arteries. The patient had developed significant intrapulmonary arteriovenous shunting. Despite the theoretical risk of worsening intrapulmonary shunting due to the decrease in systemic vascular resistance after device implantation, our patient did well. He was discharged from the hospital in stable condition and had better oxygen saturation than before the device was implanted. To our knowledge, ours is the 2nd report of the use of a ventricular assist device after the failure of a Fontan procedure, and the first report concerning the effect of ventricular assist device implantation on intrapulmonary shunting.
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14
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Miller JR, Lawrance CP, Silvestry SC. Current Options and Practices in Long-Term Ventricular Assist Devices. CURRENT SURGERY REPORTS 2014. [DOI: 10.1007/s40137-014-0053-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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15
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Lowry AW, Adachi I, Gregoric ID, Jeewa A, Morales DL. The Potential to Avoid Heart Transplantation in Children: Outpatient Bridge to Recovery with an Intracorporeal Continuous-Flow Left Ventricular Assist Device in a 14-Year-Old. CONGENIT HEART DIS 2012; 7:E91-6. [DOI: 10.1111/j.1747-0803.2012.00659.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Copeland H, Nolan PE, Covington D, Gustafson M, Smith R, Copeland JG. A method for anticoagulation of children on mechanical circulatory support. Artif Organs 2012; 35:1018-23. [PMID: 22097979 DOI: 10.1111/j.1525-1594.2011.01391.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Anticoagulation of children on mechanical circulatory support presents a challenge. We implanted 28 devices in children and infants using a consistent anticoagulation protocol. We performed a retrospective review of all children implanted in our program with mechanical assist devices since 1997. Heparin, dipyridamole, and aspirin were used for anticoagulation and antiaggregation. Coagulation monitoring included thromboelastography (TEG), platelet aggregration studies, international normalized ratio, partial thromboplastin time, and platelet count. Twenty-eight children, ages 1 month to 16 years (mean 5.3; median 2.4 years), were implanted for 3-107 days (mean 27; median 17). Eighteen received left ventricular assist devices, seven received biventricular assist devices, and three received total artificial hearts. Adverse events during the 720 days of device support included the following: six (21%) reoperations for bleeding; seven strokes (25%): two fatal, two with a mild residual deficit, and three without deficit; and three (11%) visceral emboli: two fatal and one nonfatal. There were eight deaths (29%). Causes of death were embolic (four), graft failure post-transplantation (one), preimplant anoxic brain damage (two), and postexplant heart failure (one). 24/28 (86%) survived to transplantation or weaning from device and 20/28 (71%) were discharged from the hospital, 10 after transplantation and 10 after native heart recovery. All 20 early survivors survived long term. We describe an anticoagulation protocol based upon TEG and platelet aggregation studies and using heparin, aspirin, and dipyridamole. Adequate anticoagulation is more difficult in children. However, 71% of the patients in our study survived long term.
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Affiliation(s)
- Hannah Copeland
- Department of Surgery, University of California San Diego, San Diego, CA, USA.
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18
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Current world literature. Curr Opin Cardiol 2011; 27:62-5. [PMID: 22146379 DOI: 10.1097/hco.0b013e32834f4ed9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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