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Key Concepts

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  • The parallel growth of pediatric cardiac surgery and ventricular assist device (VAD) technology has led to the development of mechanical support specifically tailored to the management of pediatric heart failure. Pediatric VADs are used for heart failure refractory to conventional medical therapy and act as bridges most often to transplantation, but may also act as a bridge to recovery. Each one of the numerous devices currently available has specific advantages, but device selection must be individualized to the patient’s particular anatomy and clinical circumstances. A large NIH trial is currently ongoing to further develop continuous flow VADs for the smaller pediatric population, due to the promising results seen in adult continuous flow device studies. Anticoagulation and infection prophylaxis remain major concerns in the management of pediatric patients undergoing VAD placement, but protocolized management will allow us to further study the complex interactions between inflammation, immunity and use of VADs in the pediatric population.

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Introduction

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Ventricular assist devices (VADs) can be invaluable tools for the management of end-stage heart failure in children. While development of such devices in adults has grown significantly since the 1960s and has led to several generations of VAD enhancements, the development of such devices in children has not grown at the same rate. This slower evolution has been due to a number of factors, such as the inherent differences in anatomic and physiologic parameters in children, especially in patients with congenital heart disease involving a variety of defects, as well as developmental changes in the coagulation system. The last 10 years, however, have witnessed an increased attention for VAD development and use in the pediatric population. This increase is due to the fact that while heart transplantation remains the ultimate therapy for children with advanced heart failure, the number of pediatric heart transplants has not increased over the past 10 years to meet the increase in demand. In fact, of all patients on the waiting list for solid-organ transplantation in the United Sates, children listed for heart transplantation face the highest waiting list mortality regardless of age.1,2 Therapeutic options, therefore, become limited at the point of end-stage heart failure, particularly with pediatric heart transplant wait times often exceeding 4 to 6 months, especially for patients 5 years of age and younger. Due to these factors, it is anticipated that more children with both congenital heart disease and cardiomyopathy-associated heart failure will require long-term VAD support in the coming decade as a bridge to transplantation or recovery.

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Historically, extracorporeal membrane oxygenation (ECMO) was the only readily accessible form of mechanical assist for both long and short-term (i.e., postcardiotomy) support. Long-term use of ECMO was limited by complications and often lack of rehabilitation of patients in preparation for transplantation. There were limited options for other long-term assist devices until 2000, when the Berlin Heart EXCOR pulsatile VAD was first utilized in a US pediatric patient under ...

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