Circulatory support with pneumatic paracorporeal ventricular assist device in infants and children

doi:10.1016/S0003-4975(98)00914-X

The Annals of Thoracic Surgery

Volume 66, Issue 5, November 1998, Pages 1498-1505

Presented at the Thirty-fourth Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 26–28, 1998.

https://doi.org/10.1016/S0003-4975(98)00914-X Get rights and content

Abstract

Background. Mechanical circulatory support in intractable heart failure in children has been limited to centrifugal pumps and extracorporeal membrane oxygenation: Since 1990 small adult-size pulsatile air-driven ventricular assist devices “Berlin Heart” (VAD) and, since 1992 miniaturized pediatric VAD (12, 15, 25, 30 mL pumps), have been used in our institution. Since 1994 the blood-contacting surfaces of the device system have been heparin-coated. In this report the experiences with VAD support in 28 children are presented.

Methods. In 28 children—ages between 6 days and 16 years—the Berlin Heart VAD has been applied for periods of between 12 hours and 98 days (mean, 16.9 days) aiming at keeping the patient alive and allowing for recovery from shock sequelae until later transplantation or myocardial recovery. There were three groups. Group I: with primary intention of “bridge-to-transplantation” in various forms of cardiomyopathy (n = 13) or chronic stages of congenital heart disease (n = 5). Group II: “Rescue” in intractable heart failure early after corrective surgery for congenital heart disease (n = 4) or in early graft failure after a heart transplantation (n = 1). Group III: “Acute myocarditis” (n = 5) aiming at either myocardial recovery or transplantation. Twelve were brought to the operating room under cardiac massage and 25 had been on the respirator for more than 24 hours.

Results. Twelve patients died on the system from sequelae of profound shock—multiorgan failure, sepsis, loss of peripheral circulatory resistance—or from hemorrhagic complications (n = 4) or brain death (n = 1). Thirteen patients (groups I and III) were transplanted after support periods of between 3 and 98 days with 7 long-term survivors living now up to 7.5 years (mean, 4.4 years). Three patients (groups II and III) were weaned from the system with two long-term survivors (both in group III). There were no patients in group II who survived and the “rescue” indication has been discarded for VAD since 1992. Such patients are since treated by extracorporeal membrane oxygenation (ECMO) in our institution. Out of the 8 patients placed on VAD during 1996 and 1997, 7 were successfully supported until transplantation or weaning. Thirteen patients were extubated and mobilized on the system. Whereas with the earlier systems thrombi in the blood pumps were seen in 15 instances and 2 patients suffered from thromboembolic complications, no thrombotic events occurred with the heparin-coated systems.

Conclusions. After accumulating clinical experience and several technical improvements since 1990 the use of the pediatric Berlin Heart VAD has matured into a reliable and safe system to keep patients with otherwise intractable heart failure alive until complete myocardial recovery is reached or transplantation becomes feasible. Whereas heart failure early after cardiac operation is now primarily treated by ECMO, acute myocarditis appears to be a promising precondition for complete cardiac recovery during VAD support.

Section snippets

Patients and methods

The Berlin Heart assist device was used in 28 children, 15 boys and 13 girls between 6 days and 16 years of age (mean, 7.5 years) from 1990 to the end of 1997. All were in profound heart failure, 25 had been on respirator for more than 24 hours, all had signs of acute renal failure as documented by oliguria-anuria, and 9 had elevated creatinine and serum urea. Twenty-one showed laboratory evidence of hepatic damage.

There were three main groups of patients according to underlying disease and

Results

The shortest support time was 12 hours (patient 7), the longest was 98 days (patient 10). The mean time in which the children were supported for was 16.9 days (± 24.2 days).

Sixteen were taken off the assist system, either after complete cardiac recovery or at time of transplantation. Twelve patients died from either loss of peripheral circulatory resistance unresponsive to α-receptor stimulants, due to multi-organ damage or due to sepsis, or from hemorrhagic complications on the assist system.

Comment

The experiences presented in this report indicate that children in advanced heart failure and even in profound cardiogenic shock, who would otherwise die immediately, may be kept alive and may either completely recover or qualify for successful heart transplantation with the aid of a pediatric version of VAD.

While the first such applications in children were made at our institution with adult size devices as early as 1990 with long-term survival after subsequent heart transplantation of now 7 $12$

Acknowledgements

Supported by Deutsche Forschungsgemeinschaft Grant no. 1669/2-1.

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Original ArticlesCirculatory support with pneumatic paracorporeal ventricular assist device in infants and children

Abstract

Section snippets

Patients and methods

Results

Comment

Acknowledgements

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Pediatr Clin North Am

Cardiovasc Surg

Mechanical circulatory support

Mechanical support and heart transplantation

J Heart Lung Transplant

Mechanical left ventricular support as bridge to cardiac transplantation in childhood

Eur J Cardiothorac Surg

Extracorporeal Life Support Registry Report 1995

ASAIO

Heart transplantation—a two-year experience

Z Kardiol

Original Articles
Circulatory support with pneumatic paracorporeal ventricular assist device in infants and children