Intensive care of the pediatric ventricular assist device patient

Complications in children with ventricular assist devices: systematic review and meta-analyses

Heart failure is a significant cause of mortality in children with cardiovascular diseases. Treatment of heart failure depends on patients' symptoms, age, and severity of their condition, with heart transplantation required when other treatments are unsuccessful. However, due to lack of fitting donor organs, many patients are left untreated, or their transplant is delayed. In these patients, ventricular assist devices (VADs) are used to bridge to heart transplant. However, VAD support presents various complications in patients. The aim of this study was to compile, review, and analyse the studies reporting risk factors and aetiologies of complications of VAD support in children. Random effect risk ratios (RR) with 95% confidence intervals were calculated to analyse relative risk of thrombosis (RR = 3.53 [1.04, 12.06] I² = 0% P = 0.04), neurological problems (RR = 0.95 [0.29, 3.15] I² = 53% P = 0.93), infection (RR = 0.31 [0.05, 2.03] I² = 86% P = 0.22), bleeding (RR = 2.57 [0.76, 8.66] I² = 0% P = 0.13), and mortality (RR = 2.20 [1.36, 3.55] I² = 0% P = 0.001) under pulsatile-flow and continuous-flow VAD support, relative risk of mortality (RR = 0.45 [0.15, 1.37] I² = 36% P = 0.16) under left VAD and biVAD support, relative risk of thrombosis (RR = 1.72 [0.46, 6.44] I² = 0% P = 0.42), infection (RR = 1.77 [0.10, 32.24] I² = 46% P = 0.70) and mortality (RR = 0.92 [0.14, 6.28] I² = 45% P = 0.93) in children with body surface area < 1.2 m² and > 1.2 m² under VAD support, relative risk of mortality in children supported with VAD and diagnosed with cardiomyopathy and congenital heart diseases (RR = 1.31 [0.10, 16.61] I² = 73% P = 0.84), and cardiomyopathy and myocarditis (RR = 0.91 [0.13, 6.24] I² = 58% P = 0.92). Meta-analyses results show that further research is necessary to reduce complications under VAD support.

Caring for Pediatric Heart Failure Patients With Long-Term Mechanical Circulatory Support

Pediatric cardiac failure is a significant problem that may be caused by cardiomyopathy, myocarditis, or congenital defects that cannot be surgically repaired. Long-term mechanical circulatory support (LTMCS) devices provide hemodynamic support for patients in heart failure as a bridge to heart transplant and, sometimes, cardiac recovery or destination therapy. Critical care nurses must have a comprehensive understanding of LTMCS device function and keen assessment skills to detect signs of impaired perfusion and device failure. Nurses should anticipate postoperative interventions, prevent adverse events, and be prepared to respond during emergencies. Patient care should be family centered and nurses must strive to maximize patients' quality of life throughout device implantation. This article provides a basic guide to caring for pediatric patients receiving LTMCS, including specific information regarding 4 devices that are often used for pediatric heart failure: Berlin Heart EXCOR, SynCardia Total Artificial Heart, HeartWare HVAD, and HeartMate II.

HeartWare Ventricular Assist Device Implantation for Pediatric Heart Failure-A Single Center Approach

While pediatric HeartWare HVAD application has increased, determining candidacy and timing for initiation of pediatric VAD support has remained a challenge. We present our experience with a systematic approach to HVAD implantation as a bridge to pediatric heart transplantation. We performed a retrospective, single center review of pediatric patients (n = 11) who underwent HVAD implantation between September 2014 and January 2018. Primary endpoints evaluated were survival to heart transplantation, need for right ventricular assist device (RVAD) at any point, ongoing HVAD support, or death. Median patient age was 11 years (range: 3-16). Median BSA was 1.25 m² (range: 0.56-2.1). Heart failure etiologies requiring support were dilated cardiomyopathy (n = 8), myocarditis (n = 1), congenital mitral valve disease (n = 1), and single ventricle heart failure (n = 1). Median time from cardiac ICU admission for heart failure to HVAD placement was 15 days (range 3-55), based on standardized VAD implantation criteria involving imaging assessment and noncardiac organ evaluation. The majority of patients (91%) were INTERMACS Level 2 at time of implant. Three patients (27%) had CentriMag RVAD placement at time of HVAD implantation. Two of these three patients had successful RVAD explanation within 2 weeks. Median length of HVAD support was 60 days (range 6-405 days). Among the 11 patients, survival during HVAD therapy to date is 91% (10/11) with 9 (82%) bridged to heart transplantation and one (9%) continuing to receive support. Posttransplant survival has been 100%, with median follow-up of 573 days (range 152-1126). A systematic approach to HVAD implantation can provide excellent results in pediatric heart failure management for a variety of etiologies and broad BSA range.