Current approaches to device implantation in pediatric and congenital heart disease patients

Abstract

The pediatric ventricular assist device (VAD) has recently shown substantial improvements in survival as a bridge to heart transplant for patients with end-stage heart failure. Since that time, its use has become much more frequent. With increasing utilization, additional questions have arisen including patient selection, timing of VAD implantation and device selection. These challenges are amplified by the uniqueness of each patient, the recent abundance of literature surrounding VAD use as well as the technological advancements in the devices themselves. Ideal strategies for device placement must be sought, for not only improved patient care, but also for optimal resource utilization. Here, we review the most relevant literature to highlight some of the challenges facing the heart failure specialist, and any physician, who will care for a child with a VAD.

Keywords:

• Berlin heart
• dilated cardiomyopathy
• heart failure
• HeartMate
• HeartWare
• mechanical circulatory support
• myocarditis
• pediatric
• ventricular assist device

Financial & competing interests disclosure

The authors were supported by the National Institutes of Health grant T32 HL007776. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Children with end-stage heart failure are optimally treated with a heart transplant. When they are unable to receive a donor heart prior to the death, they can be bridged with a ventricular assist device (VAD). Pediatric VADs have shown potential to bridge pediatric patients successfully to transplant for long periods of time.

• The current outcomes with a pediatric VAD are encouraging with survival to transplant approximately 75%, and are likely to improve.

• Although survival with a VAD is improving, many difficult and only partially understood issues remain.

  • – When to place a right VAD for biventricular VAD support rather than left VAD alone.

  • – Which device to use, and in how small of a patient can an adult continuous-flow device be safely utilized.

  • – Patient selection and the timing of implantation remain one of the most vital and difficult decisions.

  • ○ This is the most important factor determining survival and can allow for early VAD implantation to prevent the development of complications and conversely to avoid VAD placement, and its associated morbidity, in patients who are unlikely to benefit.

  • A VAD can be implanted for different etiologies of heart failure, some of which have unique implications.

  • – This includes patients with congenital heart disease and those with a single ventricle.

  • The VAD is associated with significant adverse events including cerebrovascular accident, hemorrhage and infection.

  • – New devices have the potential to further improve survival and reduce the adverse event rate.

Notes