Incremental Reduction in the Incidence of Stroke in Children Supported With the Berlin EXCOR Ventricular Assist Device

Byrnes, Jonathan W.; Prodhan, Parthak; Williams, Blake A.; Schmitz, Michael L.; Moss, Michele; Dyamenahalli, Umesh; McKamie, Wesley A.; Morrow, W. Robert; Imamura, Michiaki; Bhutta, Adnan T.

doi:10.1016/j.athoracsur.2013.06.012

Cited by 40 publications

(19 citation statements)

References 16 publications

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“…The decision to transition from ECMO to VAD is complicated and varies by clinician and center, but should be informed by an understanding of complication risks with both modes of therapy, the likelihood of myocardial recovery, and the relative benefits of VAD therapy including weaning from mechanical ventilation and sedation, and initiating rehabilitation. Stroke risk factors in pediatric VAD patients include female gender, pump replacement for thrombus, and the risk of stroke decreases incrementally as time on support progresses (22-23). As both VAD and ECMO therapies evolve, the risks for neurologic complications over time using either mode of mechanical circulatory support should be re-examined and compared in order to guide decision-making to select the optimal approach at different time points in a patient's illness (24).…”

Section: Commentmentioning

confidence: 99%

Epidemiology of Stroke in Pediatric Cardiac Surgical Patients Supported With Extracorporeal Membrane Oxygenation

Werho

Pasquali

et al. 2015

The Annals of Thoracic Surgery

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Background Stroke is a common complication of extracorporeal membrane oxygenation (ECMO), and pediatric cardiac surgical patients may be at higher risk. Epidemiology and risk factors for stroke in these patients are not well-characterized. Methods We analyzed pediatric (<18 years-old) cardiac ECMO cases in the Extracorporeal Life Support Organization Registry from 2002-2013. Cardiac surgical patients were identified and procedures stratified by Society of Thoracic Surgeons (STS) morbidity categories. The primary outcome was any stroke (hemorrhagic or infarction) identified by neuroimaging. Risk factors were identified through multivariable logistic regression. Results We analyzed 3,517 cardiac surgical patients; 81% with cyanotic disease, and 57% in high-risk STS categories (4-5). Overall, 12% developed stroke on ECMO and those with stroke had greater in-hospital mortality (72% vs. 51%, p<0.0001). In multivariable analysis, neonatal status (adjusted odds ratio 1.8, 95% confidence interval 1.3-2.4), lower weight-for-age z-score (adjusted odds ratio 1.1 for each one-point decrease, 95% confidence interval 1.04-1.25), and longer ECMO duration (upper quartile [≥167 hours] adjusted odds ratio 1.4, 95% confidence interval 1.1-1.8) were independently associated with increased stroke risk, while cyanotic disease, STS category, and bypass time were not. Conclusions This multicenter analysis demonstrates that pediatric cardiac surgical patients on ECMO are at high risk of stroke; younger or underweight patients, and those with longer ECMO duration are at greatest risk, independent of procedural complexity. Future study is necessary to determine how anticoagulation or other clinical practices can be modified to reduce stroke incidence.

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Section: Commentmentioning

confidence: 99%

Epidemiology of Stroke in Pediatric Cardiac Surgical Patients Supported With Extracorporeal Membrane Oxygenation

Werho

Pasquali

et al. 2015

The Annals of Thoracic Surgery

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“…Some authors suggested the need for a strict anticoagulation protocol and dedicated medical staff to decrease the incidence of thromboembolic complications (17).…”

Section: Neurological Complications In Bh Patientsmentioning

confidence: 99%

Long‐Term Mechanical Circulatory Support in Pediatric Patients

et al. 2015

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This retrospective study reviews our results regarding the long-term support in pediatric patients using two ventricular assist systems between January 2008 and April 2014. We implanted the Berlin Heart EXCOR in 29 patients (median age 3.4 years [interquartile range (IQR) 0.2-16.5], median weight 13 kg [IQR 4.2-67.2]). Twenty-two patients (75.8%) received a left ventricular assist device. Three patients (10.3%) had single-ventricle physiology. One patient (3.4%) had mechanical mitral valve prosthesis. The HeartWare System was implanted in nine patients. The median age was 15.6 years (IQR 12.2-17.9), and the median weight was 54.9 kg (IQR 27.7-66). In the Berlin Heart group, the median support time was 65 days (IQR 4-619), with 3647 days of cardiac support. Nineteen patients (65.5%) were transplanted, six patients (20.7%) recovered, one patient (3.4%) is on support, and three patients (10.3%) died on support. Survival rate was 89.7%. Fourteen blood pumps had been exchanged. Four patients (13.8%) had local signs of infection, and three patients (10.3%) had neurological complications. In the HeartWare group, the median support time was 180 days (IQR 1-1124), with 2839 days of cardiac support. Four patients (44.4%) had local signs of infection, and three (33.3%) had neurological complications. Eight patients (88.9%) have been transplanted, and one patient (11.1%) died on support. Survival rate was 88.9%. Excellent survival is possible after long-term mechanical circulatory support in patients with two- and single-ventricle physiology with a low rate of adverse events.

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“…A CVA can be ischemic or hemorrhagic, with ischemic being more common but hemorrhagic often being more devastating. However, it has been shown that with increased experience, and appointing a single physician to manage a patient’s anticoagulation therapy, the risk of a CVA can be decreased [59]. Also, future devices have the potential for a reduction in the degree of anticoagulation in addition to a reduced risk of CVA, which could dramatically increase survival by reducing CVAs as well as hemorrhagic complications.…”

Section: Vad Adverse Eventsmentioning

confidence: 99%

Current approaches to device implantation in pediatric and congenital heart disease patients

Miller

Lancaster

Eghtesady³

2015

Expert Review of Cardiovascular Therapy

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Summary 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 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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Incremental Reduction in the Incidence of Stroke in Children Supported With the Berlin EXCOR Ventricular Assist Device

Cited by 40 publications

References 16 publications

Epidemiology of Stroke in Pediatric Cardiac Surgical Patients Supported With Extracorporeal Membrane Oxygenation

Epidemiology of Stroke in Pediatric Cardiac Surgical Patients Supported With Extracorporeal Membrane Oxygenation

Long‐Term Mechanical Circulatory Support in Pediatric Patients

Current approaches to device implantation in pediatric and congenital heart disease patients

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