Meeting needs–pushing boundaries: Mechanical circulatory support in children; year in review

Central MessageThe persistent progress in the field of mechanical circulatory support children has led to increased use, expanded device utilization, and improved survival. The Application (MCS) become mainstream. However, it continues be associated with significant morbidity. MCS In current review, we focus on publications from year 2020 that examined role children. We include related total artificial heart (TAH) ventricular assist devices (VAD), although do not those acute extracorporeal membrane oxygenation (ECMO) support. Several registry reports shed light practice For example, Morales colleagues1Morales D.L.S. Adachi I. Peng D.M. Sinha P. Lorts A. Fields K. et al.Fourth annual pediatric interagency for (Pedimacs) report.Ann Thorac Surg. 2020; 110: 1819-1831Abstract Full Text PDF PubMed Scopus (20) Google Scholar published fourth Pediatric Interagency Registry Mechanical Circulatory Support report outlined outcomes use at 44 participating centers 2012 2019. report, there was a clear steady increase utilization. Compared third (2012-2017), which included 508 devices, number nearly doubled during 2 additional years (2017-2019) reach 1031 856 patients. Cardiomyopathy most common diagnosis (58%), followed by congenital disease (25%) myocarditis (10%). Implantable continuous (IC) flow (eg, HeartWare HVAD [Medtronic, Minneapolis, Minn] Heartmate 3 [Abbott, Abbott Park, Ill]) were commonly used, usually larger children, seems they are being used smaller than before (mean age, 13.2 ± 3.9 years). These paracorporeal pulsatile (PP) (PC) younger who also more likely have advanced failure stage 31% 46% them having Mechanically Assisted profile 1. differences explain higher survival IC compared PP PC (92% vs 81% 68% 6 months, respectively). Overall, major adverse events continue 56% experiencing least 1 event. incidence cerebrovascular seemed decreased 11%, fewer ischemic devices. Finally, whereas destination therapy remains uncommon (1.3%), VAD as bridge recovery (7.6%). Of receiving 22.6% (potentially, some these would been supported ECMO previous era).1Morales transplantation (HT) indication This year, Marcos-Alonso colleagues2Marcos-Alonso S. Gil N. García-Guereta L. Albert D. Tejero M.Á. Perez-Villa F. al.Impact transplantation.Pediatr Transplant. 24: e13707Crossref (3) Spanish Heart Transplant Group aiming examine influence HT They identified 121 underwent posttransplant between had versus not. Although found comparable groups, type outcomes. Posttransplant significantly lower 60% (P = .03), Excor (Berlin Heart, Philadelphia, Pa) (100%), other (85.7%), or biventricular (BiVAD) (67%).2Marcos-Alonso another analysis Pedimacs registry, Baez Hernandez colleagues3Baez Kirk R. Sutcliffe Davies Jaquiss Gao al.Utilization pediatrics.J Cardiovasc 160: 1301-1308.e2Abstract (4) utilization BiVAD noted trend toward lesser recent years. To assess whether reported is patient factors, performed propensity score match left 85% patients either alive awaiting (32.5%) transplanted (52.5%) months after implant. experience form bleeding. concluded different characteristics severity illness opposed themselves (despite bleeding events).3Baez an important issue given right following high mortality. Another study Simpson colleagues4Simpson K.E. Kirklin J.K. Cantor R.S. Mehegan M. Lamour J.M. Guleserian K.J. al.Right implantation children: database.J Lung 39: 231-240Abstract (9) 55% received week month implantation; morbidity factors such weight, 1, chemical paralysis, VAD, suggested developing rigorous risk model should considered potentially mortality risk.4Simpson highlighted innovative techniques Schweiger colleagues5Schweiger E Mascio C. Kanter K.R. Marasco Eghtesady Miera O. al.Intracorporeal using children.ASAIO J. 66: 1031-1034Crossref (2) HVAD. 10 (median 12.7 4.6 years; median body surface area, 1.56 m2). Overall out 10, 5 HT, none recovered.5Schweiger highlights option older children; however, decision medical, ECMO, support, devices) challenging. O'Connor colleagues6O'Connor M.J. R.R. Fynn-Thompson Joong Maeda al.Early HeartMate continuous-flow disease: multicenter analysis.J 573-579Abstract (24) described initial part Advanced Cardiac Therapies Improving Outcomes Network adults disease. implanted 35 age 15.7 (range, 8.8-47.3 years) weight 65.7 kg 19.1-114.1 kg). Congenital present (17%) 14 (40%) weighing <60 kg. excellent, only cohort. 20 (57%) waiting time, 40 days) no strokes pump thrombosis period. As such, provides reasonable implantable alternative It note time short adult populations, might difference this population. TAH subset failure. Woods colleagues7Woods R.K. Kindel Mitchell M.E. Hraska V. Niebler R.A. Evolving understanding young infants children.J 159: 1075-1082Abstract (5) presented their small (<10 kg) TAH.7Woods describe creation excision mass valved conduits inflow outflow connections centrifugal pumps (Figure 1). propose strategy (<7 selected 7 discuss rational approach BiVAD. note, done salvage procedure. Three successful good clinical status follow-up. detailed thought process learned modifications evolving experience. Accumulation regard selection, surgical will improve support.7Woods Among shifts optimism around our ability single ventricle (SV) anatomy. reflected various 2020. Philip colleagues8Philip Powers E. Machado Colon D.L. Gupta Shih al.Pulsatile transplant early high-risk single-ventricle physiology.J 2021; 162: 405-413Abstract (8) SV anatomy primary palliative procedures. Using Excor, supporting prior procedures (Norwood, pulmonary artery band, hybrid first stage, each) 4 whom operation (4 hypoplastic syndrome concomitant atresia intact septum patent ductus arteriosis stent Y shunt cannula).8Philip unique neonates extremely challenging conditions results encouraging considering otherwise expected poor prognosis 2). Only few surgeons applied similar strategy, including author article (B.A.). There lot learn nicely University Florida. Chen colleagues9Chen Rosenthal D.N. Murray Dykes J.C. Almond C.S. Yarlagadda V.V. al.Bridge disease.ASAIO 205-211Crossref (13) Stanford failing Fontan generally experience, (80%) Glenn physiology.9Chen conversion physiology moving plus simultaneous ways able numerous physiologic challenges discussion section.9Chen selection institutional affect anatomy, conclusions institutions. Granegger colleagues10Granegger Schlöglhofer T. Riebandt Schlager G. Skhirtladze-Dworschak Kitzmüller al.Mechanical bi- univentricular hearts.J Surg Open. ([Epub ahead print])PubMed 33 inferior 1-year circulation (50% 80%). excellent review about Villa colleagues.11Villa C.R. Alsaied Ventricular Fontan: story supply demand.Semin Pediatr Card Annu. 23: 62-68Abstract available literature topic point importance pathophysiology proper timing pattern Cincinnati.11Villa With rheologic performance needs carefully studied. colleagues12Granegger Thamsen B. Lach Escher Haas al.Blood trauma potential patients.J 1519-1527Abstract (12) produced elegant data along silico vitro blood cohort (body 1.19 0.36 m2) 60-day 90% but 43% event 8 weeks implantation. Further modeling showed speeds flows counterparts result trauma.12Granegger Studies Pediatric-specific well management strategies needed mitigate On direct thrombin inhibitors (bivalirudin argatroban) anticoagulant (to heparin) gaining community. Various safety bivalirudin may suggest superiority unfractionated heparin.13VanderPluym C.J. Boyle May Griffiths treated support.ASAIO 939-945Crossref (25) Scholar,14Bates Buchholz H. Freed MacArthur PiDBorochynski Conway Bivalirudin heterogeneous population.ASAIO 677-682Crossref (10) saw validation continued patients, mainly recovery. cardiomyopathy good. challenge field. Innovative approaches combined better technology necessary optimize care.