title: Mechanical bridging to orthotopic heart transplantation in children weighing less than 10 kg: feasibility and limitations.
abstract: OBJECTIVE
  Infants and young children are considered the most difficult group to bridge to orthotopic heart transplantation (OHT) and data regarding outcomes are scarce.
  
  
  METHODS
  We reviewed our patients ≤ 10 kg with those who were bridged to OHT using ventricular assist device (VAD) Berlin Heart (BH) Excor ± extracorporeal membrane oxygenation (ECMO) between 2004 and 2009.
  
  
  RESULTS
  Eleven children ≤ 10 kg with end-stage heart failure (cardiomyopathy or myocarditis) were treated with VAD as bridge to OHT: the median weight was 8.0 (range 3.9-10.0 kg)kg and median age was 12.3 (range 1.2-33.9 months) months. Five (45%) required ECMO support pre-BH and six were on mechanical ventilation and inotropes. In 9/11 (82%), the support mode was left ventricular assist device (L-VAD) (all alive): one of two patients needing Bi-VAD support died. On BH, the median support time was 27 days and time to extubation was 8 days. Two out of 11 (18%) suffered strokes confirmed on brain imaging; both recovered and one underwent resection of infarcted small bowel. Ten out of 11 (91%) were transplanted, one remains in hospital and nine are at home in good health. When compared to patients >10 kg bridged with BH (n = 15), the mortality (p = 0.51) and rates of neurological complications (p = 0.54) were similar. Post-transplant recovery (ventilation times and time to home discharge) was similar between the bridged children ≤ 10 kg and non-bridged children ≤ 10 kg who underwent OHT.
  
  
  CONCLUSIONS
  Mechanical bridging to transplantation is clinically feasible in children ≤ 10 kg, achieving excellent outcomes. Judicious use of VADs in smaller children will optimise the use of donor organs; however, the effect on overall OHT waiting times, if mechanical bridging was extended to a large number of small children, is unknown.
authors.affiliation: The Cardiothoracic Unit, Great Ormond Street Hospital for Children NHS Trust, London, UK. Karima@gosh.nhs.uk
authors.forename: Ann
authors.initials: A
authors.lastname: Karimova
authors.forename: Carin
authors.initials: C
authors.lastname: Van Doorn
authors.forename: Katherine
authors.initials: K
authors.lastname: Brown
authors.forename: Alessandro
authors.initials: A
authors.lastname: Giardini
authors.forename: Martin
authors.initials: M
authors.lastname: Kostolny
authors.forename: Mary
authors.initials: M
authors.lastname: Mathias
authors.forename: Aparna
authors.initials: A
authors.lastname: Hoskote
authors.forename: Michael
authors.initials: M
authors.lastname: Burch
mesh_terms: D000293:Adolescent; D001835:Body Weight; D002648:Child; D002675:Child, Preschool; D015199:Extracorporeal Membrane Oxygenation / Q000009:adverse effects / Q000379:methods; D005240:Feasibility Studies; D005260:Female; D006333:Heart Failure / Q000209:etiology / Q000601:surgery / Q000628:therapy*; D016027:Heart Transplantation; D006353:Heart-Assist Devices / Q000009:adverse effects; D006801:Humans; D007223:Infant; D008297:Male; D012189:Retrospective Studies; D016896:Treatment Outcome