Original Investigation
Ventricular Assist Device Support as a Bridge to Transplantation in Pediatric Patients

https://doi.org/10.1016/j.jacc.2018.04.072Get rights and content
Under an Elsevier user license
open archive

Abstract

Background

Pediatric ventricular assist device (VAD) use has evolved dramatically over the last 2 decades.

Objectives

This study sought to describe the evolution of VAD support to heart transplantation (HTx) in children in a large international multicenter cohort.

Methods

Using data from the Pediatric Heart Transplant Study, comparisons were made between children (<18 years) supported to HTx (January 1, 1993 to December 31, 2015) with VAD or extracorporeal membrane oxygenation (ECMO) to VAD support.

Results

Of 7,135 listed patients, 5,145 underwent HTx; 995 (19.3%) were supported by a VAD (113 with congenital heart disease [CHD]). Patients with a VAD as their first device (n = 821) were older, larger, and more likely to have cardiomyopathy (80%) than patients transitioned from ECMO to VAD (n = 164). In the VAD-only cohort, 79% underwent HTx and 14% died, compared with 69% and 24% in the ECMO-to-VAD cohort, respectively. Patients with cardiomyopathy achieved HTx 84% of the time, with a 9% waitlist mortality rate compared with 55% and 36%, respectively, for CHD. Among VAD-treated patients, 79% were age >10 years in the earliest era, a percentage decreasing to 34% more recently, though neonates still represent <1%. Overall, survival at 2 and 20 years showed no difference between VAD and no support (2 years: 75% vs. 80%; 20 years: 55% vs. 54%). Post-HTx outcomes were better for durable versus temporary VADs (p < 0.01) and for continuous versus pulsatile VADs (p < 0.01) from 2005 onward; timing of VAD had no impact on post-HTx survival (p = 0.65).

Conclusions

For one-quarter of a century, major advances have occurred in mechanical support technology for children, thereby expanding the capability to bridge to HTx without compromising post-HTx outcomes. Significant challenges remain, especially for neonates and patients with CHD, but ongoing innovation portends improved methods of support during the next decade.

Key Words

durable
extracorporeal membrane oxygenation
heart failure
outcomes
survival

Abbreviations and Acronyms

BiVAD
biventricular VAD
ECMO
extracorporeal membrane oxygenation
LVAD
left ventricular assist device
MCSD
mechanical circulatory support device
PediMACS
Pediatric Interagency Registry for Mechanical Circulatory Support
RVAD
right ventricular assist device
UNOS
United Network for Organ Sharing
VAD
ventricular assist device

Cited by (0)

Dr. Rosenthal has received research support from Berlin Heart; and has received educational meeting support from HeartWare. Dr. Kirklin has received a stipend as Chair of the data and safety monitoring board for the Xeltis pediatric extracardiac conduit trial; and has received institutional support as principal investigator of the INTERMACS National Mechanical Circulatory Support Registry. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Listen to this manuscript's audio summary by JACC Editor-in-Chief Dr. Valentin Fuster.