New era of pediatric ventricular assist devices: Let us go to school

As there is still a shortage of pediatric donor hearts, several techniques have been used to assist pediatric patients to survive until transplantation. VADs provide long‐term support and ability of mobilization for children before a suitable heart becomes available. Several devices such as paracorporeal pumps have been used for this purpose, with acceptable morbidity and mortality rates. However, discharge is not possible, as there is no mobile drive unit for these small‐sized pumps. The possible negative psychosocial impact of long‐term hospitalization, away from home and school, may cause some adjustment problems in the future. In this case series, three pediatric patients that underwent intracorporeal LVAD implantation and returned to school are presented to share clinical experience and also to attract attention to the potential social and psychiatric implications.     

External ventricular assist devices as circulatory support in patients with dilated cardiomyopathy

Ventricular assist devices have demonstrated their utility in patients with intractable cardiac failure, both as support until complete myocardial recovery and as a bridge to transplantation. Specific pediatric pneumatic paracorporeal systems can be applied even in infants. Long-term survival has been reported although experience is limited. We report the case of an 8-year-old boy with dilated cardiomyopathy awaiting cardiac transplantation. The patient developed profound cardiogenic shock with multiorgan failure while being evaluated for heart transplantation. He was given biventricular assistance with the MEDOS-HIA system (MEDOS-Helmholtz Institute). Maximum stroke volume ventricles of 25 and 22 ml were used, achieving a cardiac output of 2.2 l/min in both ventricles. The patient was supported with ventricular assistance for 9 days, but multiple organ failed to improve and transplantation became impossible. Progressive loss of peripheral circulatory resistance unresponsive to treatment developed and ventricular assistance was discontinued. The previous severe shock and advanced and progressive multiorgan failure could be responsible for the poor outcome of our patient despite maintenance of adequate cardiac output. Nevertheless, the use of ventricular assist devices is a real therapeutic alternative in children with severe cardiogenic shock, allowing them to recover completely or undergo heart transplantation. Patient selection, the choice of a system of appropriate size, and early implantation seem to be the cornerstones for obtaining good results.     

Pediatric ventricular assist devices

End stage heart failure is a growing problem in the pediatric population. These patients are conventionally managed with a combination of oral and intravenous medications. When these fail, mechanical circulatory support is indicated. Improvements in technology have made options for mechanical circulatory support available to infants and children. These devices may be indicated as a bridge to recovery of the native heart function, or, more commonly as a bridge to transplant. Particularly in small patients, extracorporeal life support (ECMO) has been historically used for this purpose. In some cases, adult ventricular assist devices have been used in older children. At the current time, there are devices in clinical use or being developed that will further improve the care and outcomes of these patients. In this article, the indications, implementation, and results of pediatric ventricular assist devices are presented.     

The use of mechanical assist devices in the pediatric population

The last two decades have witnessed an expansion in the devices, support strategies, and outcomes for pediatric patients who require mechanical circulatory support. The use of large registries that house data on these devices and the development of shared learning networks have provided clinicians with the ability to critically assess outcomes for emerging and existing technology. The purpose of this review is to provide the reader with perspective on the most contemporary devices utilized for pediatric mechanical circulatory support. It will examine existing support strategies and the most contemporary outcomes regarding these devices including those in high risk patients.     

Outcomes of Berlin Heart EXCOR® pediatric ventricular assist device support in patients with restrictive and hypertrophic cardiomyopathy

The outcomes of pediatric ventricular assist device support in patients with diastolic heart failure have not been well described. This study reviews the North American experience with Berlin Heart EXCOR^® ventricular assist device implants in children with such physiology. The Berlin Heart clinical database was reviewed. Patients with primary diastolic dysfunction are included in this study. Twenty pediatric patients with restrictive cardiomyopathy (n = 13), hypertrophic cardiomyopathy (n = 3), or congenital heart disease with restrictive physiology (n = 4) who were supported with EXCOR^® were identified. Of these, nine (45%) were successfully bridged to transplant, one (5%) weaned from support, and 10 (50%) died after support was withdrawn. Of patients under age 3 years (n = 13), 38.5% survived, whereas those aged 3 or older (n = 7) had 71.4% survival (P = .35). Biventricular assist device (BiVAD) patients experienced a 27.3% survival, vs 77.8% for patients with left ventricular assist device only (P = .07). Primary causes of death included stroke, infection, acidosis, multisystem organ failure, and bleeding. Pediatric patients with diastolic heart failure comprise a high‐risk population for mechanical circulatory support. However, half of patients with this physiology have been successfully supported to explant with EXCOR^®. The trends toward higher mortality for younger patients and those receiving BiVAD support warrant consideration.     

小儿心肌病研究进展及展望

心肌病(cardliomyopathy)是小儿时期非常严重的疾病,合并心力衰竭占71%-90%,患儿预后差,存活者伴有持久的心肌损害及心肌功能不全.     

Talking with caregivers of children living in the community with ventricular assist devices

A VAD is a mechanical pump used to support the functioning of a failing heart. As a pediatric therapy, a VAD is used as a temporary solution for poor heart function, a bridge to transplantation or recovery, or a destination therapy. The goal of this qualitative study was to explore the perspectives of family and professional caregivers of children who are supported by VADs in outpatient settings. Semi‐structured interviews were conducted with 22 caregivers of school‐aged children discharged home on VAD support. Interviews were transcribed, and data were analyzed using qualitative content analysis. Caregivers identified issues facing children on VAD support in the contexts of home, school, and other childhood places including being physically connected to a device; experiencing changes; living a medical life; negotiating restrictions; cost of care; family, kinship, and community; and, present and future living. While a child with a VAD may have much in common with other medically complex children, the technological complications and risks of living with a VAD are uniquely identified by caregivers as an issue, especially when considering the way that children with a VAD are connected to their device—implanted yet exterior, mobile yet restricted, and autonomous yet dependent.     

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.     

Biventricular support with HeartWare ventricular assist device in a pediatric patient

Use of ventricular assist devices is increasing in the pediatric population. This has included the extended use of adult continuous‐flow devices in the pediatric population. In a minority of cases, biventricular support may be needed. In these situations, biventricular support with continuous‐flow devices can be surgically challenging, and therefore, only few cases have been reported. Here, we present a case of implantation of two HeartWare HVAD devices for biventricular support for a decompensating patient with acute myocarditis as well as present an alternative implantation surgical strategy.     

Outcome of pediatric heart transplantation recipients treated with ventricular assist device

This study was conducted to evaluate the long‐term prognosis of pediatric HTx patients treated with VAD before transplantation. The clinical data of six patients bridged to HTx with Berlin Heart EXCOR pediatric device were analyzed retrospectively. Information about graft function, CA results, and EMB findings as well as appearance DSA was collected. Also, information about growth and cognitive function was analyzed. These findings were compared with age‐, gender‐, and diagnosis‐matched HTx patients. During the median follow‐up time of four and half yr after HTx, the prognosis including graft function, number of rejection episodes, and incidence of coronary artery vasculopathy, growth and cognitive development did not differ between VAD‐bridged HTx patients compared with control patients. In both groups, one patient developed positive DSA titer after HTx. Our single‐center experience suggests that the prognosis of pediatric HTx patients treated with VAD before transplantation is not inferior to that of other HTx patients.     

Mechanical embolectomy for ischemic stroke in a pediatric ventricular assist device patient

The reported incidence of cerebral embolic or hemorrhagic complications related to mechanical circulatory support in children is high, even while subjects are managed with aggressive antithrombotic therapy. The safety and utility of endovascular treatment for stroke in the pediatric VAD population has not been established in the published literature. We describe a nine‐yr‐old patient on BiVAD support who experienced threatened AIS on two separate occasions. He was treated successfully via mechanical embolectomy on both occasions and survived to transplantation with minimal neurologic deficits.     

Depression and anxiety levels of the mothers of children and adolescents with left ventricular assist devices

Ozbaran B, Kose S, Yagdi T, Engin C, Erermis S, Yazici KU, Noyan A, Ozbaran M. Depression and anxiety levels of the mothers of children and adolescents with left ventricular assist devices. Abstract: VADs have been used to provide treatment for end‐stage heart failure. Parents may feel overwhelmed with the VAD regimes responsibility and be affected from this process beside children. In this study, we aimed to evaluate the depressive and anxiety symptoms of mothers of the first eight children equipped with a VAD in Turkey. The mothers of eight pediatric patients living with VADs were filled BDI and STAI at first month of VAD implantation (E.I) and secondly six months after their first evaluation (E.II). In E.I, the BDI mean score of mothers was 20.87, in E.II 14.37. STAI‐S mean score was 53.37 in E.I and 43.62 in E.II. The Wilcoxon nonparametric‐paired t‐test revealed significant difference between baseline and end‐point STAI‐S scores (Z: ?2.035; p: 0.042), and for BDI scores (Z, ?1.965; p, 0.049). Prolonged usage of VAD may increase distress in parents. Psychiatric evaluation and support of the primary caregiver is important for the well‐being of the pediatric patients.