Mechanical circulatory support in pediatric patients – a review of 15 years

Introduction: End stage cardiac failure in children is a frustrating diagnosis. Mechanical circulatory support (VAD) is sometimes the only possible treatment either to bridge for transplantation or to stabilize the circulatory situation in order to treat a transient cardiac failure.

Methods: Between 1997 and 2011 we treated 28 patients (30 applications) in end stage cardiac failure with different extracorporeal VAD Systems. From 1997 to 2001 we implanted the Medos Excor (group A) in 11 patients (LVAD n=5, RVAD n=2, BiVAD n=4), median age 2y (r: 20d-11y). Diagnosis of group A consisted of: DCM n=5, myocarditis n=2; postcardiotomy n=2, post HTX n=2. From 2006 to 2011, the Berlin Heart System (group B), 17 pts (19 applications) (LVAD n=7, BiVAD n=12), median age 8y (r: 95d-19y). In group B patients suffered from DCM/RCM n=14; chronic myocarditis n=2; ischemic cardiomypathy due to sclerodermia n=1. Application of VAD in group A was elective in 7 pts., urgent in 4 pts., in group B elective in 8, urgent in 11 procedures. ECMO was performed only in group B in 11 patients as a bridge to VAD.

Results: In group A 5 pts. (45%) survived, 3 bridged to HTX, 2 recovered. Median VAD therapy was 9d (r.: 0.5–30d). 6 pts. died (ARDS n=2, brain death n=2, sepsis n=1, bleeding n=1).

In group B 11 pts. (65%) survived, 7 bridged to HTX, 4 to recovery. Median VAD time was 30d (r:8–283d). 6 pts. (35%) died (sepsis n=4, brain death n=2).

Increased risk of mortality was associated with pre-VAD cerebral insult (odds-ratio: 12.8, infection on VAD (odds-ratio: 5.3) and surgical revision on VAD (odds-ratio:4.2).

Conclusion: In end stage cardiac failure VAD therapy in pediatric patients is successful as a bridge to transplant or to recovery. Serious complications are always possible, so that VAD-therapy should be postponed as long as possible. Reducing infections and bleeding during VAD therapy is a mayor step to an improved outcome.