Bridge to Transplant with Ventricular Assist Device Support in Pediatric Patients with Single Ventricle Heart Disease

Abstract

Ventricular assist device (VAD) support for children with single ventricle (SV) heart disease remains challenging. We performed a single-center retrospective review of SV patients on VAD support and examined survival to transplant using the Kaplan–Meier method. Patients transplanted were compared with those who died on support. Between 2009 and 2017, there were 14 SV patients with 1,112 patient-days of VAD support. Stages of palliation included pre-Glenn (n = 5), Glenn (n = 5), and Fontan (n = 4). Eight patients (57%) were successfully bridged to transplant at a median 107 days. Deaths occurred early (n = 6, median 16 days) and in smaller patients (10.1 vs. 28.3 kg, P = 0.04). All Fontan patients survived to transplant, whereas only 20% of Glenn patients survived to transplant. Adverse events occurred in 79% (n = 11). Five patients met hospital discharge criteria, with two patients (one pre-Glenn, one Glenn) discharged and transplanted after 219 and 174 days of VAD support. All transplanted patients were discharged at a median 21 days posttransplant. SV patients in various stages of palliation can be successfully bridged to transplant with VAD support. With use of intracorporeal continuous-flow devices, longer-term support and hospital discharge are possible.

ISHLT consensus statement for the selection and management of pediatric and congenital heart disease patients on ventricular assist devices Endorsed by the American Heart Association

“…Given donor shortage, there are many reports in recent years (2014-2019) of SVAD support for Fontan patients as BTT. 42,180,184,[193][194][195][196][197][198][199][200][201][202][203] There are also case reports of DT SVAD support for Fontan patients, 204 as well as VAD support of the pulmonary circulation. 205 Additionally, SVAD support in Fontan patients as bridge to combined multiorgan (heart-liver, heart-kidney) transplant have not yet been reported.…”

“…Durable CF 184,[193][194][195][196][197][198]204 and PF devices, 180,[198][199][200][201] as well as temporary support devices, 202 have been used in Fontan patients as BTT. Recently, there has been increasing use of durable CF devices including the HeartMate 3 197 and HVAD.…”

“…Recently, there has been increasing use of durable CF devices including the HeartMate 3 197 and HVAD. 184,[193][194][195][196]198,204 PF devices (EXCOR) should be considered for patients who cannot receive a durable CF device (typically due to size). 180,[198][199][200][201] Right and left sided ("biventricular") support has been reported using the TAH 42 or BiVAD support (with EXCOR 199 or HVAD 194 ).…”

Meeting needs–pushing boundaries: Mechanical circulatory support in children; year in review

“…Although they noted that supporting SV patients with failing Fontan was generally successful in their experience, they reported significant mortality (80%) in those supported with the Glenn physiology. 9 They suggested either conversion to shunt physiology or moving on to Fontan operation plus simultaneous VAD as alternative ways to be able to support these patients given the numerous physiologic challenges in children with Glenn physiology that they described nicely in their discussion section. 9 It is likely that patient selection and institutional experience affect MCS outcomes in children with SVanatomy, and that might explain different results and conclusions from various institutions.…”

“…9 They suggested either conversion to shunt physiology or moving on to Fontan operation plus simultaneous VAD as alternative ways to be able to support these patients given the numerous physiologic challenges in children with Glenn physiology that they described nicely in their discussion section. 9 It is likely that patient selection and institutional experience affect MCS outcomes in children with SVanatomy, and that might explain different results and conclusions from various institutions. Granegger and colleagues 10 reported outcomes of MCS in 33 children and found that MCS in children with SV anatomy was associated with inferior 1-year survival compared with patients with biventricular circulation (50% vs 80%).…”