Despite the fact that VADs are now regarded as an important treatment option in pediatric heart failure, most hospitals perform less than 10 VAD surgeries in children a year. “ISHLT consensus statement for the selection and management of pediatric and congenital heart disease on VADs” gives expert-consensus derived recommendations, emphasizing the importance of multicenter collaboration and real-world data to drive meaningful change in the field.
The literature review was published in the Journal of Heart and Lung Transplantation’s August 2021 digital issue. Topics covered include patient selection, indications, intent, pre-implant planning, device selection, operative management, post-operative hemodynamic goals, anticoagulation management, support strategies for unique pediatric populations (including single ventricle patients), preparing for transplantation, discharge, post-transplant survival, end of life care, quality improvement, and registry development.
- Over one-third of patients transplanted are being bridged to transplant (BTT) with a VAD, as shown in the 2019 ISHLT report.
- Patients have better outcomes when they receive a VAD before end-organ dysfunction or clinical deterioration; however, more research is needed to understand if VADs can stabilize critically ill children experiencing advanced heart failure. There is evidence that a paracorporeal continuous flow (CF) device can improve end-organ dysfunction in children.
- Pre-implant planning needs to include assessment of end-organs, surgical planning, and psychosocial factors. Optimal timing depends on a number of potential risks and benefits.
- Generally, intracorporeal CF devices are mostly used in children >15-20kg. The Berlin EXCOR is considered in children <20kg. The paracorporeal CF devices are used as bridge to recovery (BTR), in patients who need BiVAD support, and as a BTT in some high-risk populations.
- Review cardiac morphology and physiology data (presence of shunts, collateral vessels, and the location and course of great vessels) when assessing for a durable VAD. Shunts should be closed during the VAD surgery (some exceptions in the Fontan patients).
- See Pedimacs report for common adverse event rates. (Table 2 in the consensus statement).
- The section on support strategies for unique pediatric populations includes CF VAD in small patients, Muscular Dystrophies, Chemotherapy-Induced Cardiomyopathies, and Adult Congenital Heart Disease.
- The section on single ventricle patients describes increased use (and success) of durable VAD implant in Fontan patients with heart failure due to systemic ventricular dysfunction.
- Patients on VAD support listed for heart transplant should be tested for anti-HLA sensitization, with the knowledge that some antibodies may only be present transiently.
- Clinicians should regularly communicate with parents and patients regarding symptom management, decision-making, and known potential adverse events.
The literature review features expert opinion from many leaders in ACTION: Angela Lorts, Jennifer Conway, Iki Adachi, Shahnawaz Amdani, Scott R Auerbach, Mark S Bleiweis, Elizabeth Blume, Danielle Burstein, Ari Cedars, Sharon Chen, Melissa Cousino-Hood, Kevin P Daly of Boston Children’s Hospital, Lara A Danziger-Isakov, Nicole Dubyk, Joshua Friedland-Littlel, Robert Gajarski, Beth Hawkins, Aamir Jeewa, Steven Kindel, Jodie Lantz, Sabrina Law, Katsuhide Maeda, Jacob Mathew, Lindsay May, Jenna Murray, Robert A Niebler, Matthew O’Connor, David Peng, Joseph Philip, Leigh Christopher Reardon, David N Rosenthal, Joseph Rossano, Kurt Schumacher, Kathleen Simpson, David Sutcliffe, Hari Tunuguntla, Christina VanderPluym, Chet Villa, Peter Wearden, Farhan Zafar, Matthew Zinn, Independent Reviewers David Morales, Jennifer Cowger, Holger Buchholz, and Antonio Amodeo.
Lorts A, Conway J, Schweiger M, Adachi I, Amdani S, Auerbach SR, Barr C, Bleiweis MS, Blume ED, Burstein DS, Cedars A, Chen S, Cousino-Hood MK, Daly KP, Danziger-Isakov LA, Dubyk N, Eastaugh L, Friedland-Little J, Gajarski R, Hasan A, Hawkins B, Jeewa A, Kindel SJ, Kogaki S, Lantz J, Law SP, Maeda K, Mathew J, May LJ, Miera O, Murray J, Niebler RA, O’Connor MJ, Özbaran M, Peng DM, Philip J, Reardon LC, Rosenthal DN, Rossano J, Salazar L, Schumacher KR, Simpson KE, Stiller B, Sutcliffe DL, Tunuguntla H, VanderPluym C, Villa C, Wearden PD, Zafar F, Zimpfer D, Zinn MD, Morales IRD, Cowger J, Buchholz H, Amodeo A. ISHLT consensus statement for the selection and management of pediatric and congenital heart disease patients on ventricular assist devices Endorsed by the American Heart Association. J Heart Lung Transplant. 2021 Aug;40(8):709-732. doi: 10.1016/j.healun.2021.04.015. Epub 2021 May 20. PMID: 34193359.