Steroid Therapy as a Strategy to Treat Hyperfibrinogenemia in Pediatric Ventricular Assist Device Patients: Does It Actually Hasten the Decline?

Abstract

The increasing heart transplant waitlist time for children supported with a ventricular assist device (VAD) has brought into question the impact of support duration on post-transplant outcomes. We sought to analyze the effect of VAD support duration on pre-transplantation condition as well as post-transplantation outcomes in children. Methods: United Network of Organ Sharing (UNOS) database from 2011-2014 had 317 pediatric patients with a long-term VAD implant (≤ 18 y) and support duration data available. Patients were divided into two cohorts based on duration of support (55 days). Fifty-five days was found to be the inflection point of increasing hazard of mortality using cox-proportional hazard model. Results: A total of 135 patients were supported for 55days. Age (7.8±6.4 vs 7.8±6.3; p= 0.67), diagnosis (CHD-15% vs 15%, CMP-78% vs 82%; p= 0.36), use of pulsatile VAD (73% vs 67%; p= 0.23) and incidence of sensitization (39% vs 47%; p= 0.186), was similar between the two groups. Survival was better for patients supported longer (87% vs 95% at 1yr, 81% vs 94% at 3 yrs; p= 0.018) [Figure 1a], even after removing continuous flow VADs. Patients supported longer were more likely to have improvement in pre-transplant condition from listing to transplant. (Figure 1b) The incidence of stroke identified post-transplant (12% vs 4%; p= 0.04) was less in patients supported longer; additionally, post-transplant length of stay (26±23 vs 24±30; p= 0.678), drug treated rejection in 1 st year (15% vs 17%; p= 0.892) and poor functional status at follow up (12% vs 8%; p= 0.360) was similar between the two groups. Conclusion: Longer duration of mechanical support not only improves pre-transplant condition but is also associated with better graft survival and patient outcome. These analyzes may be helpful at a time when changes in pediatric listing policies are being considered.

Lessons Learned from Managing Antithrombotic Therapy in Children Supported with Pediatric Ventricular Assist Devices

“…No clear difference in the rate of drop between children who received two versus 1 mg/kg of prednisone was evident, and the study was too small to show a difference in outcomes. 16 Thus, for paracorporeal pumps, it is common to administer steroids in children with a fibrinogen level >600 mg/dl favoring the dose of 2 mg/kg initially recommended by Byrnes et al 15 and included in ACTION guidelines. When infection or sepsis is the cause of hyperfibrinogenemia, a lower dose of 1 mg/kg can be used, or delayed until antibiotics are given or hemodynamic stability has been achieved.…”