Pediatric ventricular assist devices: Bridge to a new era of perioperative care

Abstract

Summary Pediatric ventricular assist devices (VADs) are evolving as a standard therapy for end stage heart failure in children. Major recent developments include the increased use of continuous flow (CF) devices in children and increased experience with congenital heart disease (CHD) and outpatient management. In the current and future era anesthesiologists will encounter more children presenting for VAD implantation, subsequent procedures and heart transplantation. Successful perioperative management requires an understanding of the interaction between the patient's physiology and the device and a framework to troubleshoot problems. This review focuses on CF devices, VAD support for CHD and perioperative management of pulsatile and CF devices in the pediatric population.

A Review of Physiologic Considerations and Challenges in Pediatric Patients With Failing Single- Ventricle Physiology Undergoing Ventricular Assist Device Placement

“…Additionally, recent reports highlight the ability of CF devices to generate higher flows at lower filling pressures when compared to pulsatile systems. For these reasons, implementing CF devices may be preferred in single ventricle patients with systemic-pulmonary shunts using EXCOR cannulas in combination with a centrifugal pump [18][19][20] . Surgical strategies combining the use of EXCOR cannulas with centrifugal pumps, such as the CentriMag (Abbott, IL, USA) and PediMag (Abbott, IL, USA) devices, additionally provide the ability to exchange a centrifugal device with an EXCOR device when long term-support is necessary to facilitate maximum rehabilitation.…”

“…which may be amenable to interventional coil embolization postoperatively. With the deconstruction of the cavopulmonary anastomosis during device implantation (i.e., SVC reattached to the right atrium with the addition of a systemic to pulmonary shunt to provide pulmonary blood flow), such significant desaturations are unlikely 20 .…”

“…Varying degrees of valvular regurgitation predispose patients to systemic venous congestion, impaired pulmonary blood flow, and subsequent hypoxemia 20 that may contribute to the rapid development of acute pulmonary dysfunction and early mortality in patients with pre-existing BDG palliation or de-novo creation of BDG at the time of device placement 31 . In patients with previous SCPC shunts, hypoxemia necessitates volume administration and avoidance of hyperventilation to augment pulmonary blood flow 26,38,39 .…”

“…In patients with previous SCPC shunts, hypoxemia necessitates volume administration and avoidance of hyperventilation to augment pulmonary blood flow 26,38,39 . The presence of acquired vascular collateral vessels may predispose patients to an increased risk of bleeding on subsequent sternotomies, exacerbated in malnourished patients with impaired tissue integrity, compromised hemostasis due to hepatic venous congestion, and wound healing 20 . Elevations in PVR in the setting of cyanosis post-VAD therapy should raise clinical suspicion for systemic venous hypertension that may require coil embolization of aortopulmonary collaterals with a low threshold to use ECMO or incorporate an oxygenator if a CentriMag circuit is present.…”

Ventricular assist device support for complex congenital heart disease: Inspiration from history of surgical evolution

“…As previous studies have repeatedly shown, VAD outcomes for Profile 1 patients are sub-optimal. 4 This would be even more so the case in the Stage 1 population, which explains the dismal outcomes (i.e., the nature of salvage VAD in extremely fragile patients). In comparison, <25% of Stage 2 patients are Profile 1, which suggests different reasons for the equally poor outcome.…”