title: Outcome of mechanical cardiac support in children using more than one modality as a bridge to heart transplantation.
abstract: OBJECTIVE
  Mechanical cardiac support (MCS) can successfully be applied as a bridging strategy for heart transplantation (OHTx) in children with life-threatening heart failure. Emergent use of MCS is often required before establishing the likelihood of OHTx. This can require bridge-to-bridge strategies to increase survival on the waiting list. We compared the outcome of children with heart failure who underwent single MCS with those who required multiple MCS as a bridge to OHTx.
  
  
  METHODS
  A retrospective study of patients aged less than 16 years was conducted. From March 1998 to October 2005, we used either a veno-arterial extracorporeal membrane oxygenator (VA-ECMO), or the Medos® para-corporeal ventricular assist device (VAD). From November 2005 onwards, the Berlin Heart EXCOR® (BHE) device was implanted in the majority of cases. Several combinations of bridge-to-bridge strategies have been used: VA-ECMO and then conversion to BHE; BHE and then conversion to VA-ECMO; left VAD and then upgraded to biventricular support (BIVAD); conversion from pulsatile to continuous-flow pumps.
  
  
  RESULTS
  A total of 92 patients received MCS with the intent to bridge to OHTx, including 21 (23%) supported with more than one modality. The mean age and weight at support was similar in both groups, but multimodality MCS was used more often in infancy (P = 0.008) and in children less than 10 kg in weight (P = 0.02). The mean duration of support was longer in the multiple MCS group: 40 ± 48 vs 84 ± 43 days (P = 0.0003). Usage of multimodality MCS in dilated cardiomyopathy (19%) and in other diagnoses (29%) was comparable. Incidence of major morbidity (haematological sequelae, cerebrovascular events and sepsis) was similar in both groups. Survival to OHTx/explantation of the device (recovery) and survival to discharge did not differ between single MCS and multiple MCS groups (78 vs 81% and 72 vs 76%, respectively).
  
  
  CONCLUSIONS
  Bridge to OHTx with multiple MCS does not seem to influence the outcome in our population. Infancy and body weight less than 10 kg do not tend to produce higher mortality in the multiple MCS group. However, children receiving more than one modality are supported for longer durations.
authors.affiliation: Department of Paediatric Cardiac Surgery, Freeman Hospital, Newcastle Upon Tyne, UK fabrizio.derita@gmail.com.
authors.forename: Fabrizio
authors.initials: F
authors.lastname: De Rita
authors.affiliation: Department of Paediatric Cardiac Surgery, Freeman Hospital, Newcastle Upon Tyne, UK.
authors.forename: Asif
authors.initials: A
authors.lastname: Hasan
authors.affiliation: Department of Paediatric Intensive Care, Freeman Hospital, Newcastle Upon Tyne, UK.
authors.forename: Simon
authors.initials: S
authors.lastname: Haynes
authors.affiliation: Department of Paediatric Cardiac Surgery, Freeman Hospital, Newcastle Upon Tyne, UK.
authors.forename: Edward
authors.initials: E
authors.lastname: Peng
authors.affiliation: Department of Paediatric Cardiac Surgery, Freeman Hospital, Newcastle Upon Tyne, UK.
authors.forename: Fabrizio
authors.initials: F
authors.lastname: Gandolfo
authors.affiliation: Department of Paediatric Intensive Care, Freeman Hospital, Newcastle Upon Tyne, UK.
authors.forename: Lee
authors.initials: L
authors.lastname: Ferguson
authors.affiliation: Department of Paediatric Cardiology, Freeman Hospital, Newcastle Upon Tyne, UK.
authors.forename: Richard
authors.initials: R
authors.lastname: Kirk
authors.affiliation: Department of Paediatric Intensive Care, Freeman Hospital, Newcastle Upon Tyne, UK.
authors.forename: Jon
authors.initials: J
authors.lastname: Smith
authors.affiliation: Department of Paediatric Cardiac Surgery, Freeman Hospital, Newcastle Upon Tyne, UK.
authors.forename: Massimo
authors.initials: M
authors.lastname: Griselli
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D015199:Extracorporeal Membrane Oxygenation / Q000009:adverse effects; D016027:Heart Transplantation / Q000379:methods*; D006353:Heart-Assist Devices / Q000009:adverse effects; D006801:Humans; D007223:Infant; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome
keywords: ECMO; Heart failure; Heart transplantation; Mechanical circulatory support; Paediatrics