Mechanical Circulatory Support of the Critically Ill Child Awaiting Heart Transplantation

Abstract

The majority of children awaiting heart transplantation require inotropic support, mechanical ventilation, and/or extracorporeal membrane oxygenation (ECMO) support. Unfortunately, due to the limited pool of organs, many of these children do not survive to transplant. Mechanical circulatory support of the failing heart in pediatrics is a new and rapidly developing field world-wide. It is utilized in children with acute congestive heart failure associated with congenital heart disease, cardiomyopathy, and myocarditis, both as a bridge to transplantation and as a bridge to myocardial recovery. The current arsenal of mechanical assist devices available for children is limited to ECMO, intra-aortic balloon counterpulsation, centrifugal pump ventricular assist devices, the DeBakey ventricular assist device Child; the Thoratec ventricular assist device; and the Berlin Heart. In the spring of 2004, five contracts were awarded by the National Heart, Lung and Blood Institute to support preclinical development for a range of pediatric ventricular assist devices and similar circulatory support systems. The support of early development efforts provided by this program is expected to yield several devices that will be ready for clinical trials within the next few years. Our work reviews the current international experience with mechanical circulatory support in children and summarizes our own experience since 2005 with the Berlin Heart, comparing the indications for use, length of support, and outcome between these modalities.

Effect of counter-pulsation control of a pulsatile left ventricular assist device on working load variations of the native heart

“…When a pulsatile left ventricular assist device (LVAD) is used to support the blood pumping function of the damaged native heart of a patient in end-stage heart failure, it is important to consistently supply sufficient blood flow to the aorta [ 1 - 3 ]. Furthermore, it is important to reduce the variations in the physical load of the left ventricle (LV) during LVAD support because severe cardiac load variations can shorten the monophasic action potential duration of repolarization of the native heart (QT interval), thus increasing the risk of ventricular tachycardia or fibrillation [ 4 - 9 ].…”

Chronic In Vivo Testing of the Penn State Infant Ventricular Assist Device

“…The anticoagulation regimen was based on protocols generally used with pediatric VADs in infants 2,16-18 . Unfractionated heparin is usually started when hemostasis has been established, with a target aPTT of 60-70 secs.…”

The American Heart Association's Recent Scientific Statement on Cardiac Critical Care: Implications for Pediatric Practice

“…As in adults, the critical care of children with heart failure has advanced significantly with the advent of mechanical support as a bridge to transplantation. 15 The recently completed prospective trial of mechanical support in children with severe heart failure demonstrated improved survival with a pediatric ventricular assist device compared with ECMO support. 16 This, coupled with the Food and Drug Administration's approval of the Berlin Heart device for use in children and upcoming trials of other devices in smaller children, will undoubtedly increase the population of children surviving with heart failure.…”

“…Congenit Heart Dis. 2013;8: [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19] These issues are also of significance in the provision of pediatric cardiac intensive care and will need to be addressed. A report by Stromberg in 2004 64 highlighted the "profound discrepancy between the current and growing need for trained pediatric cardiac intensivists and the graduation rate of these professionals from teaching programs."…”