Ventricular assist devices as a bridge-to-transplant improve early post-transplant outcomes in children.
BACKGROUND
The use of ventricular assist devices (VADs) to bridge pediatric patients to transplant or recovery has been expanding. There are few current pediatric data assessing the impact of VAD support on post-transplant survival.


METHODS
We performed a retrospective review of all pediatric (≤18 years old, n = 4,028) transplants performed between 1995 and 2011 and contained within the United Network for Organ Sharing data set. Transplants were divided into three eras: early (1995 to 2002, n = 1,450); intermediate (2003 to 2007, n = 1,138); and recent (2008 to 2011, n = 1,440). VADs were present at transplant in 398 patients (9.8%). Outcomes among patients with and without VADs were assessed and compared across eras.


RESULTS
The use of VADs for bridge to transplant has increased (early 1.1%, intermediate 10.5%, recent 17.9%; p < 0.0001). Mean weight among VAD-supported patients (early 63.5 kg, intermediate 42.3 kg, recent 28.8 kg; p < 0.0001) has decreased during this period. VAD patients <10 kg had an increased risk of stroke (odds ratio [OR] = 4.9, 95% confidence interval [CI] 2.1 to 10.8) compared with non-mechanical support patients. In multivariable analyses, extracorporeal VADs were the only type of VAD associated with higher post-transplant mortality (OR = 3.0, 95% CI 0.8 to 10.6). Other types of VAD had lower mortality (OR = 0.5, 95% CI 0.2 to 1.0). Long-term survival was unaffected by the use of a VAD pre-transplant.


CONCLUSIONS
Pediatric patients bridged to transplantation with VADs are increasingly younger and smaller. Complication rates remain high among patients <10 kg. Early post-transplant survival among intracorporeal and paracorporeal VAD patients is excellent and better when compared with unsupported patients. The use of short-term support devices is associated with higher post-transplant mortality. Long-term survival is unaffected by VAD use.
Nemours Cardiac Center, Nemours/A.I. duPont Hospital for Children, Wilmington, Delaware; Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania. Electronic address: rdavies@nemours.org.
Ryan R
RR
Davies
Nemours Cardiac Center, Nemours/A.I. duPont Hospital for Children, Wilmington, Delaware.
Shylah
S
Haldeman
Nemours Cardiac Center, Nemours/A.I. duPont Hospital for Children, Wilmington, Delaware; Department of Pediatrics, Thomas Jefferson University, Philadelphia, Pennsylvania.
Michael A
MA
McCulloch
Nemours Cardiac Center, Nemours/A.I. duPont Hospital for Children, Wilmington, Delaware; Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania.
Christian
C
Pizarro
D002311:Cardiomyopathy, Dilated / Q000150:complications; D002648:Child; D002675:Child, Preschool; D005260:Female; D006330:Heart Defects, Congenital / Q000150:complications; D006333:Heart Failure / Q000209:etiology / Q000401:mortality* / Q000628:therapy*; D016027:Heart Transplantation; D006353:Heart-Assist Devices; D006801:Humans; D015994:Incidence; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D011183:Postoperative Complications / Q000453:epidemiology; D012189:Retrospective Studies; D015996:Survival Rate; D016896:Treatment Outcome
extracoporeal membrane oxygenation; heart transplantation; mechanical circulatory support; pediatrics; survival; ventricular assist device