Can Destination Therapy be implemented in children with heart failure? A study of provider perceptions

Abstract

DT is an established final therapeutic choice in adult patients with severe heart failure who do not meet criteria for cardiac transplantation. Patients are given VADs, without the prospect of care escalation to transplantation. VADs are now established therapy for children and are currently used as a bridge until transplantation can be performed or heart failure improves. For children who present in severe heart failure but do not meet transplantation criteria, the question has emerged whether DT can be offered. This qualitative study aimed to elicit the perspectives of early adopters of DT at one of the few institutions where DT has been provided for children. Responses were recorded and coded and themes extracted using grounded theory. Interviewees discussed: envisioning of the DT candidate; approach to evaluation for DT; contraindications to choosing DT; and concerns about choosing DT. Providers articulated two frameworks for conceptualizing DT: as a long bridge through resolution of problems that would initially contraindicate transplantation or, alternatively, as a true destination instead of transplantation. True destination, however, may not be the lasting concept for long-term VAD use in children given improvement in prognosis for current medical contraindications and improving VAD technology.

Mechanical circulatory support challenges in pediatric and (adult) congenital heart disease

“…In pediatrics the concept of destination therapy may be different when compared to adult provider beliefs. Char et al suggested that 'providers are reaching a point where they can consider long-term VAD for patients with contraindications to transplant that have the potential to improve, or even can be stabilized long enough for future therapies to emerge [34]. In this sense, destination therapy in children may become more like a long bridge to decision, rather than the adult concept of destination therapy as a true 'destination' [34].…”

Cardiac destination therapy in pediatrics – Are we there yet?

“…In the current issue of the journal, Char et al have begun to explore this topic from the perspective of providers through semi‐structured interview at one of the few pediatric VAD programs that has implanted VADs as destination therapy (DT) as declared at the time of implantation. The study is limited by the single‐center nature of the study; however, the comments documented in the study seem to accurately reflect the opinion of many providers within the pediatric VAD community and thus are novel and important data in what is likely to be a growing patient population.…”

CPR and Ventricular Assist Devices: The Challenge of Prolonging Life Without Guaranteeing Health

“…In children, VADs have also begun to assume an important role in the treatment of end-stage heart failure (O'Connor and Rossano 2014), and pediatric VAD DT has also begun to emerge as a clinical possibility for children with end-stage heart failure who are ineligible for transplantation (Char et al 2016). Although there are accepted criteria for VAD support in adults, indications and contraindications for VAD support in children are still being established (Feldman et al 2013;Miller and Guglin 2013).…”

“…Discontinuing VAD in a child can be emotionally very difficult for providers as well as families, much more so than VAD discontinuation in the adult DT population (Char et al 2016). Similarly, with improving VAD technologies that could allow safe, long-term VAD use until suitable transplantation, and with continuing improvements in outcomes for diseases that contraindicate transplant, like muscular dystrophies, clinicians have not yet been ready to accept "destination" for all of their patients, instead viewing pediatric VAD as a bridge and longer bridge (Char et al 2016). Barg and colleagues (2017) describe patients as entering a liminal, or undefined, state of being neither sick nor healthy, with no culturally scripted role or identity once they undertake VAD.…”

“…Possible indications include systemic diseases traditionally thought to be contraindications to cardiac transplantation (e.g., Duchenne muscular dystrophy or mitochondrial diseases); recent or slow growing malignancy; single ventricle; heart failure and other organ disease (a situation that might lead to bridge to multiple-organ transplant vs. DT); severe obesity; ongoing infection (secondary to poor nutrition/cardiac cachexia); diabetes with end-organ damage; cross-match incompatibility; psychiatric or other nonlethal limitations; and substance abuse or other "social" contraindications. Given the complexity of these potential pediatric VAD DT indications, it is unresolved which, if any, pediatric patients exist who have a contraindication that would prohibit transplantation but could safely tolerate VAD (Char et al 2016).…”