Abstract
Purpose: Although most children with cardiomyopathy (CMP) or myocarditis can be supported with left ventricular assist device (LVAD) only, some develop right heart failure (RHF) requiring aggressive pharmacotherapy or bi-ventricular (BiVAD) support. We aim to a) describe RHF, b) identify risk factors and c) assess impact on morbidity/mortality in children supported with VAD. Methods and Materials: All children treated with VAD Excor Berlin Heart at two paediatric transplant centres since 2004 were reviewed. RHF was defined as: a) signs of impaired RV (ECHO confirmed) with CVP 15mmHg and poor LVAD filling with prolonged ( 96 hours) need for intravenous inotropes (excluding milrinone) and/or iNO; b) need for BiVAD. In both centres the practice is to treat with LVAD; BiVAD is reserved for refractory RHF. Results: Of 53 children bridged with VAD, 23 (43%) developed RHF; 12 needed BiVAD and 11 were managed on LVAD. The weight of patients with RHF was 19 (3.6-90) kg compared to 11(3.8-68) kg in those without (p 0.16). The rate of RHF in children with non-dilated CMP (restrictive or hypertrophic), myocarditis and those with dilated CMP was 86%, 57% and 36% respectively (p 0.04). RHF was more likely in patients supported with ECMO preVAD: 14/23 (61%) vs 10/30 (33%) (p 0.04). Notably 10 of 12 children who needed BiVAD had ECMO preVAD. Additionally, RHF children had higher creatinine (p 0.03) and bilirubin (p 0.003) pre-implantation. Post-implantation, renal replacement therapy was more common in the RHF group (34% vs 7%, p 0.03) while there was no difference in the length of ventilation (p 0.15). Overall survival to transplant was 87% (45/53). Survival was similar in children managed on LVAD with or without RHF (92% and 89% respectively) and was lower in the BiVAD group (64%). Conclusions: Preliminary findings indicate that 2 in 5 children treated with VAD are likely to develop RHF, particularly those with non-dilated CMP and those who were on ECMO pre VAD. Further research into mechanisms and management of RHF on VAD in children is needed.
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