Outcomes of pediatric patients supported with continuous-flow ventricular assist devices: A report from the Pediatric Interagency Registry for Mechanical Circulatory Support (PediMACS)

Rossano, Joseph W.; Lorts, Angela; VanderPluym, Christina; Jeewa, Aamir; Guleserian, Kristine J.; Bleiweis, Mark S.; Reinhartz, Olaf; Blume, Elizabeth D.; Rosenthal, David N.; Naftel, David C.; Cantor, Ryan S.; Kirklin, James K.

doi:10.1016/j.healun.2016.01.1228

Cited by 114 publications

(82 citation statements)

References 19 publications

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“…Although VAD support carries substantial risk, its use can restore normal cardiac output to those waiting for a suitable donor . Indeed, the increased use of VADs in children has reduced waitlist mortality and improved post‐transplant outcomes, likely due to improved end‐organ function during the support period …”

Section: Introductionmentioning

confidence: 99%

Renal injury and recovery in pediatric patients after ventricular assist device implantation and cardiac transplant

Hollander

Cantor

Sutherland

et al. 2019

Pediatric Transplantation

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Background The use of ventricular assist devices (VADs) in children with heart failure may be of particular benefit to those with accompanying renal failure, as improved renal function is seen in some, but not all recipients. We hypothesized that persistent renal dysfunction at 7 days and/or 1 month after VAD implantation would predict chronic kidney disease (CKD) 1 year after heart transplantation (HT). Methods Linkage analysis of all VAD patients enrolled in both the PEDIMACS and PHTS registries between 2012 and 2016. Persistent acute kidney injury (P‐AKI), defined as a serum creatinine ≥1.5× baseline, was assessed at post‐implant day 7. Estimated glomerular filtration rate (eGFR) was determined at implant, 30 days thereafter, and 12 months post‐HT. Pre‐implant eGFR, eGFR normalization (to ≥90 mL/min/1.73 m2), and P‐AKI were used to predict post‐HT CKD (eGFR <90 mL/min/1.73 m2). Results The mean implant eGFR was 85.4 ± 46.5 mL/min/1.73 m2. P‐AKI was present in 19/188 (10%). Mean eGFR at 1 month post‐VAD implant was 131.1 ± 62.1 mL/min/1.73 m2, significantly increased above baseline (P < 0.001). At 1 year post‐HT (n = 133), 60 (45%) had CKD. Lower pre‐implant eGFR was associated with post‐HT CKD (OR 0.99, CI: 0.97‐0.99, P = 0.005); P‐AKI was not (OR 0.96, CI: 0.3‐3.0, P = 0.9). Failure to normalize renal function 30 days after implant was highly associated with CKD at 1 year post‐transplant (OR 12.5, CI 2.8‐55, P = 0.003). Conclusions Renal function improves after VAD implantation. Lower pre‐implant eGFR and failure to normalize renal function during the support period are risk factors for CKD development after HT.

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Section: Introductionmentioning

confidence: 99%

Renal injury and recovery in pediatric patients after ventricular assist device implantation and cardiac transplant

Hollander

Cantor

Sutherland

et al. 2019

Pediatric Transplantation

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“…In the most recent Registry Report from the International Society for Heart and Lung Transplantation, nearly 50% of children with dilated cardiomyopathy were bridged to heart transplantation on some form of mechanical circulatory support, with the vast majority supported with a left ventricular assist device . Although the overall survival of pediatric patients supported with VADs has improved and is similar to adult VAD patients for certain devices, there are few data on the costs associated with VAD use in pediatric patients …”

Section: Introductionmentioning

confidence: 99%

Resource Utilization in Pediatric Patients Supported With Ventricular Assist Devices in the United States: A Multicenter Study From the Pediatric Interagency Registry for Mechanically Assisted Circulatory Support and the Pediatric Health Information System

Rossano

Cantor

Dai

et al. 2018

JAHA

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BackgroundFew data exist on resource utilization with pediatric ventricular assist devices (VADs). We tested the hypothesis that device type and adverse events are associated with increased resource utilization in pediatric patients supported with VADs.Methods and ResultsThe Pediatric Interagency Registry for Mechanically Assisted Circulatory Support, a national registry of VADs in patients <19 years old, and the Pediatric Health Information System, an administrative database, were merged. Univariate analysis was performed assessing the association of all factors with the total cost and length of stay first. Significant variables (P<0.05) were subjected to multivariable analysis. The study included 142 patients from 19 centers with VAD implants from October 2012 to June 2016. The median age was 9 years (interquartile range [IQR] 2‐15), 84 (59%) supported with a continuous‐flow VAD. Overall median hospital costs were $750 000 (IQR $539 000 to $1 100 000) with a median hospital length of stay of 81 days (IQR 54‐128). On multivariable analysis, device type and postoperative complications were not associated with resource utilization. Factors associated with increased costs included patient age, lower‐volume VAD center, being intubated, being on extracorporeal membrane oxygenation, number of complex chronic medical conditions, and length of stay. Among continuous‐flow VAD patients, discharge to home before transplant versus remaining hospitalized was associated with lower hospital costs (median $600 000 [IQR $400 000 to $820 000] versus median $680 000 [IQR $500 000 to $970 000], P=0.03).Conclusion VADs in pediatric patients are associated with high resource utilization. Increased resource utilization was associated with lower‐volume VAD centers, disease severity at VAD implantation, and the presence of complex chronic medical conditions. Further study is needed to develop cost‐effective strategies in this complex population.

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“…Several transitional probabilities were modeled as table variables whereby their value differed based on the Markov cycle count to represent the evolving nature of the patient's medical state (Table ) . Given the model did not stratify by neurologic event severity, it was assumed that such an event did not change the transplant listing status.…”

Section: Methodsmentioning

confidence: 99%

Cost‐utility of continuous‐flow ventricular assist devices as bridge to transplant in pediatrics

Evers

Villa

Wittekind

et al. 2019

Pediatric Transplantation

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Objective The initial costs of a CF‐VAD exceed those of a PF‐VAD. However, the safety profile of CF‐VAD is superior and the possibility of outpatient device support may justify the additional initial costs. This study analyzed the cost‐utility of CF‐VAD use in the pediatric population. Methods A Markov‐state transition model was constructed for the clinical course of the two VAD subtypes from implantation until death with variables extracted from internal financial records and the published literature. The modeled population consisted of pediatric heart failure patients who met indications for VAD implant (INTERMACS profile 1 or 2) and were size‐eligible for either a PF‐VAD or CF‐VAD. Results The cost‐utility analysis illustrated that CF‐VAD is both more effective and less costly compared to PF‐VAD at base‐case conditions. Sensitivity analyses demonstrated that only in extreme conditions did a CF‐VAD strategy not meet criteria for cost‐effectiveness (if readmission rate >20% weekly, neurologic event rate >8% weekly, or CF‐VAD discharge rates <18% in a month) or VAD support duration shortens to ≤12 weeks. Conclusion While the implantation costs of a CF‐VAD exceed those of a PF‐VAD, after 12 weeks of device support CF‐VAD becomes the more cost‐effective strategy if the anticipated outpatient device care is sufficiently long. The cost efficacy of the CF‐VAD will be further heightened as initiatives that result in earlier and safer discharges, as well as reductions in readmission rates continue to be successful.

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Outcomes of pediatric patients supported with continuous-flow ventricular assist devices: A report from the Pediatric Interagency Registry for Mechanical Circulatory Support (PediMACS)

Abstract: CF VADs are commonly utilized in older children and adolescents, with excellent survival rates. Further study is needed to understand impact of patient and device characteristics on outcomes in pediatric patients.

Cited by 114 publications

References 19 publications

Renal injury and recovery in pediatric patients after ventricular assist device implantation and cardiac transplant

Renal injury and recovery in pediatric patients after ventricular assist device implantation and cardiac transplant

Resource Utilization in Pediatric Patients Supported With Ventricular Assist Devices in the United States: A Multicenter Study From the Pediatric Interagency Registry for Mechanically Assisted Circulatory Support and the Pediatric Health Information System

Cost‐utility of continuous‐flow ventricular assist devices as bridge to transplant in pediatrics

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