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j.jacc.2017.09.009

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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
VOL. 70, NO. 18, 2017
ª 2017 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 0735-1097/$36.00
PUBLISHED BY ELSEVIER
http://dx.doi.org/10.1016/j.jacc.2017.09.009
EDITORIAL COMMENT
Expanding the Use of Temporary
Ventricular Assist Devices
in Pediatric Patients
Rise of the Machines*
Jennifer Conway, MD,a Sabin J. Bozso, MDb
T
he use of ventricular assist devices (VADs) in
Procurement
the pediatric population continues to gain in-
compares outcomes in children undergoing bridge to
and
Transplantation
Network
that
terest among clinicians as an alternative to
heart transplantation (HT) with a TCS device or
extracorporeal membrane oxygenation (ECMO) for
ECMO. Supporting the increased interest in this field,
temporary circulatory support (TCS). In the pediatric
the authors found that the number of TCS devices
population, extracorporeal membrane oxygenation
increased dramatically during the study period,
(ECMO) has been the traditional method of TCS
from <3 per year before 2011 to 50 in 2015. Overall,
whereas durable VADs have been reserved for
164 patients underwent PS matching with 82 patients
longer-term support. The interest in the use of tem-
in the ECMO and TCS cohorts, respectively. The study
porary VAD support in pediatrics has grown likely
found that the support duration was longer and sur-
from the ability to evaluate for recovery, assess the
vival to transplant better in the TCS cohort compared
neurologic status and potential for decreased compli-
with the ECMO cohort, translating into a 2-fold higher
cations, and determine treatment options without the
waitlist survival, and a modest 90-day reduction in
time constraints of ECMO. Despite the potential ad-
pre-transplant mortality (45% ECMO, 39% TCS) with
vantages, the use of TCS with VAD has lagged behind
no significant difference in post-HT survival. Impor-
the use of long-term VADs, likely a reflection of the
tantly, this study is the largest to date and first to
limited published experience of single case reports
suggest that patient survival is superior with TCS
or small case series (1–3) and the need for central can-
devices compared with ECMO.
nulation for most of the devices in pediatrics. For
The survival benefit to TCS with VAD over ECMO
these reasons, further studies reporting the outcomes
seen in this study may be due to a variety of mecha-
of TCS with VAD compared with ECMO are important
nisms. Several different VAD pumps exist including
to determine the optimal treatment strategy.
the CentriMag and PediMag (Thoratec, Pleasanton,
California), Maquet Rotaflow (DataScope/Maquet,
SEE PAGE 2250
Rastatt, Germany), Impella (Abiomed, Danvers, Mas-
In this issue of the Journal, Yarlagadda et al. (4)
sachusetts), and TandemHeart (CardiacAssist, Pitts-
reported a retrospective propensity score (PS)–
burgh, Pennsylvania). Each of these devices varies in
matched
terms of mechanical composition and potential
study
using
data
from
the
Organ
configuration during implantation with unique advantages and disadvantages. Namely, the CentriMag
*Editorials published in the Journal of the American College of Cardiology
and PediMag are magnetically levitated with no
reflect the views of the authors and do not necessarily represent the
bearing or seals with the added benefit of potentially
views of JACC or the American College of Cardiology.
less thrombus formation (5). Another potential source
From the aDivision of Pediatric Cardiology, Department of Pediatrics,
of complication seen with ECMO can arise from the
Stollery Children’s Hospital, University of Alberta, Edmonton, Canada;
and the bDivision of Cardiac Surgery, Department of Surgery, University
oxygenator required to provide respiratory support.
of Alberta, Edmonton, Canada. The authors have reported that they have
In contrast, VAD circuits can be utilized with or
no relationships relevant to the contents of this paper to disclose.
without an oxygenator, thus in cases where an
2262
Conway and Bozso
JACC VOL. 70, NO. 18, 2017
OCTOBER 31, 2017:2261–3
Temporary Support and Pediatrics
oxygenator is not required, a benefit may be seen
application of TCS support as a bridge to HT must
with VAD support over ECMO.
be tempered pending further analysis of safety
Support duration was significantly longer for TCS
outcomes.
devices compared with ECMO (median 19 days vs.
The use of TCS with VAD has already gained wide
6 days; p < 0.001) in this study. Despite the signifi-
adoption with adults, yet remains a relatively novel
cantly longer bridge duration, a similar number of
approach in the pediatric population (8). As with any
patients remained on support at the time of trans-
emerging therapy, defining criteria for optimal pa-
plant (ECMO 54% vs. TCS 68%; p ¼ 0.25) with no
tient selection poses a significant challenge. The lack
significant difference
post-HT survival. This
of clear safety outcomes remains the largest barrier to
observation implies that early identification of pa-
expansion of the use of short-term VAD support in the
tients who may benefit from TCS coupled with early
pediatric
initiation of support may lead to increased survival to
Interagency
transplant and ultimately improved outcomes for
Support) registry collects data on short-term VADs
children faced with end-stage heart failure awaiting
including survival and adverse events. Emerging
heart transplantation. Although the field has tradi-
analysis from the PEDIMACS registry will help to
tionally categorized many of these pumps as short
better elucidate factors that may influence survival
term the reality is that a number of them are being
along with incidence of adverse events during short-
used for longer-term support, as highlighted by the
term VAD support to develop optimal patient selec-
25th to 75th interquartile range of support for the
tion criteria.
in
CentriMag-PediMag patients of 12 to 62 days.
population.
Registry
The
for
PEDIMACS
Mechanical
(Pediatric
Circulatory
The current report provides the first demonstrable
Although the results of the current report are
survival advantage to TCS devices over ECMO for
encouraging, there are several points that warrant
children as a bridge to HT. The results of the present
further discussion. First, the survival rate post-HT
report increase our confidence surrounding the use of
after bridging with ECMO support in this study is
TCS devices as a bridge to HT in the pediatric popu-
higher than previously reported and in fact is no
lation and suggest that temporary VAD support is
different than those on TCS (6). This is likely related
now emerging as a tool for managing end-stage heart
to the PS-matching algorithm, where very ill ECMO
failure refractory to medical therapy. Although this
patients were less likely to be PS matched to a simi-
study lends support to the use of temporary VAD for
larly ill TCS patient. Therefore, the general conclusion
bridge to HT, emerging analysis of registry data will
that there is no difference in post-transplant out-
provide the comparative safety profiles of VAD and
comes on patients supported with a temporary VAD
ECMO. Although this study included only children
compared with ECMO would be incorrect and needs
undergoing bridge to HT, further study is required to
to be taken into the context of the patients included
evaluate the use of TCS devices in a broad category of
in this study. Furthermore, the indication for TCS
indications. Use of short-term VAD support has
with VAD or ECMO in this study was isolated to bridge
expanded dramatically in the pediatric population
to HT. TCS with VAD has been used for a variety of
and enthusiasm for this technique will likely continue
indications in the pediatric patient, however, given
to grow. Ongoing refinement of TCS devices will
the narrow inclusion criteria we are limited in making
continue to promote their increased utilization,
generalizations about these devices for broader
expanding the therapeutic options for children with
application (7). Finally, although the present study
end-stage heart failure, and ultimately leading to
provides support to the feasibility of TCS as a bridge
improved outcomes and reduced mortality.
to HT with superior survival compared with ECMO,
very little is known about the morbidity encountered
ADDRESS
by these patients. There has been no comparison to
Conway, Department of Pediatrics, Stollery Children’s
FOR
CORRESPONDENCE:
date between ECMO and TCS with respect to the
Hospital,
adverse events encountered and the impact they have
Northwest, 4C2, Edmonton, Alberta T6G 2B7, Canada.
on outcomes. Thus, our enthusiasm for a broader
E-mail: conway@ualberta.ca.
University
of
Alberta,
Dr. Jennifer
8440-112
Street
REFERENCES
1. Contrafouris CA, Chatzis AC, Kanakis MA,
Azariadis PA, Mitropoulos FA. Postcardiotomy mechanical circulatory support in two infants with Wil-
2. Kumar TKS, Ballweg J, Knott-Craig CJ. Lessons
learned with the use of CentriMag as short-term
ventricular assist device in a child. Cardiol Young
3. Gerrah R, Charette K, Chen JM. The first successful
use of the levitronix PediMag ventricular support
device as a biventricular bridge to transplant in an
liams’ syndrome. Case Rep Surg 2014;2014:795726.
2015;25:603–5.
infant. J Thorac Cardiovasc Surg 2011;142:1282–3.
Conway and Bozso
JACC VOL. 70, NO. 18, 2017
OCTOBER 31, 2017:2261–3
Temporary Support and Pediatrics
4. Yarlagadda VV, Maeda K, Zhang Y, et al.
Temporary circulatory support in U.S. children
awaiting heart transplantation. J Am Coll Cardiol
2017;70:2250–60.
6. Dipchand AI, Mahle WT, Tresler M, et al. Extracorporeal membrane oxygenation as a bridge to pediatric
heart transplantation: Effect on post-listing and posttransplantation outcomes. Circ Heart Fail 2015;8:960–9.
8. Stretch R, Sauer CM, Yuh DD, Bonde P.
National trends in the utilization of short-term
mechanical circulatory support: Incidence, outcomes, and cost analysis. J Am Coll Cardiol
5. Hoshi H, Shinshi T, Takatani S. Third-generation blood pumps with mechanical noncontact
magnetic bearings. Artif Organs 2006;30:
324–38.
7. Conway J, Al-Aklabi M, Granoski D, et al. Supporting pediatric patients with short-term
continuous-flow devices. J Heart Lung Transplant
2016;35:603–9.
2014;64:1407–15.
KEY WORDS pediatrics, short-term devices,
temporary support
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