Outcomes of Children Supported With Pulsatile Paracorporeal Ventricular Assist Device: Congenital Versus Acquired Heart Disease

A case of truncus arteriosus with severe heart failure and pulmonary stenosis: bridge to transplant candidacy with surgical correction and a ventricular-assist device

Ventricular-assist device therapy for small patients with congenital heart disease is challenging due to its complex anatomy and hemodynamics. We describe a 3-year-old patient with heart failure with truncus arteriosus in the palliative stage. The patient underwent palliative right ventricular outflow tract reconstruction following bilateral pulmonary artery banding. At 6 months of age, the patient developed severe truncal valve regurgitation and left ventricular dysfunction. Emergent truncal valve replacement with a mechanical valve was performed, but left ventricular dysfunction persisted. At 3 years of age, the patient developed acute progression of heart failure triggered by influenza infection. The patient was intubated and transferred to our center to determine the indication for heart transplantation. On the second day after admission, signs of multiorgan failure appeared. Emergent ventricular-assist device implantation for both ventricles was performed with truncal valve closure, ventricular septal defect closure, atrial septal defect closure, and re-right ventricular outflow tract reconstruction. The right ventricular-assist device was successfully removed on the seventh postoperative day. Due to the small pulmonary arteries, severe pulmonary stenosis persisted after ventricular-assist device implantation, but it gradually improved with multiple pulmonary angioplasties. The patient was registered in the Japanese organ transplant network and is awaiting a donor organ in a stable condition.

Analysis of UNOS: Berlin Heart Bridge to Transplant in Acquired vs Congenital Heart Disease

BACKGROUND

This study evaluated long-term survival in pediatric patients who were bridged to transplantation with the Berlin Heart ventricular assist device by comparing patients with congenital heart disease (CHD) with patients with acquired heart disease (AHD).

METHODS

The United Network for Organ Sharing Database was queried for patients (aged <18 years) who received a heart transplant in the United States and were preoperatively supported with the Berlin Heart ventricular assist device. Patients were stratified by a diagnosis of AHD vs CHD. Univariable and multivariable analyses were performed to assess baseline characteristics and posttransplant survival.

RESULTS

This cohort included 806 patients (n = 573 AHD, n = 233 CHD). Patients with CHD and AHD were of similar size (weight [kg], 12.8 ± 9.27 vs 15.3 ± 13.6; P = .107), and most were aged <1 year (34.9%; n = 281) or 1 to 5 years (45.3%; n = 365). Ventricular assist device configuration differed between patients with CHD and AHD: 70.4% (n = 164) vs 75% (n = 430) were supported with a left ventricular assist device, 9.9% (n = 23) vs 0.7% (n = 4) were supported with a right ventricular assist device, and 19.7% (n = 46) vs 24.3% (n = 139) were supported with a biventricular assist device (P < .001). Patients with CHD were more often male (57.1% [n = 133] vs 46.9% [n = 269]; P = .011), and they had worse estimated 5-year posttransplant survival at 74.3% (95% CI, 67.5%-81.7%) compared with 85.8% (95% CI, 82.5%-89.2%) in patients with AHD. However, for patients who survived the first year after transplantation, posttransplantation survival was similar between the groups (P > .05 at 2, 3, 4, and 5-years). In multivariable analysis, a CHD diagnosis was significantly associated with an increased risk for mortality (hazard ratio, 1.645; 95% CI, 1.075-2.487; P = .021).

CONCLUSIONS

After controlling for demographic variations and pretransplant risk factors, patients with CHD who were bridged to transplant with the Berlin Heart ventricular assist device had worse long-term survival than patients with AHD who were bridged to transplant with the Berlin Heart ventricular assist device.