COMMENTARY

Bridging Children to Heart Transplantation: Ventricular Assist Devices

Joseph Rossano, MD, MS

Disclosures

January 12, 2015

Editorial Collaboration

Medscape &

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I'm Joe Rossano. I am the medical director of the Heart Failure Transplant Program here at The Children's Hospital of Philadelphia. I am going to speak to you about our ventricular assist device (VAD) program.

Heart failure is an important disease in pediatric cardiology, and a number of children with cardiomyopathies or palliated congenital heart disease will unfortunately develop refractory heart failure and require heart transplantation. The mortality while waiting for transplant in children is still very high, and much higher than it is in adults. In order to support the circulation effectively so that children can undergo transplant, mechanical circulatory support is often needed.

We are fortunate to have a number of devices that we are able to utilize that can be very effective in supporting the circulation in infants as small as a few kilograms to adult-sized patients. For our young children, the only long-term, durable device that is approved is the Berlin Heart® EXCOR Pediatric VAD. A trial[1] of this device a few years ago clearly demonstrated its efficacy over what otherwise currently would be available as extracorporeal membrane oxygenation (ECMO) or total cardiopulmonary support. ECMO was only good generally for several days, or perhaps a few weeks. In this study, nobody was alive on ECMO after 25 days, so the Berlin heart was clearly superior. Somewhere around 70%-80% of children will be bridged successfully to transplant with the Berlin heart VAD.

For our older children, we can utilize some devices that are designed for adults. These include the implanted intracorporeal continuous flow devices, such as the HeartMate II® (Thoratec Corporation; Pleasanton, California) and the HeartWare® (HeartWare International Inc.; Framingham, Massachusetts). These are very durable devices with significantly less side effects than some of the older paracorporeal pulsatile pumps. These have been utilized very successfully in children, mostly as a bridge to transplant. Occasionally they have been used in what has been called "destination therapy," meaning that the patient would live their entire life on a VAD with no expectation of doing a transplant. These devices allow us to send patients home. They can be very stable and durable, and certainly most adults on these devices are out of the hospital.

Because circulation is so well supported, we can focus a lot on rehabilitation so we have our children up, active, getting strong, and generally going into transplant in much better shape than they were before the devices were implanted.

There are still a number of circulations that are very challenging to support. Some complex congenital heart diseases are very difficult to support mechanically for the long term. For some of these patients, we have utilized a total artificial heart or an additional pump for patients that have a single ventricle, which can be very challenging. As well, very small infants, especially those weighing less than 3 kg, are a challenging group to support.

This is an area of active research, and we are very hopeful that we will have better devices in the future and be able to continue to make strides even greater than we have over the past 10 years.

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