Advanced Heart Failure in Adolescents: A Challenge for A Newly Established Program in the Middle East

Abstract

Introduction Management of advanced heart failure (HF) is challenging enough in the adult population and significantly more so in adolescents. Our newly established advanced HF and transplant program predominantly caters for adults. Nevertheless, being the only center in the country and one of two in the Gulf Region, we are faced with managing younger patients presenting with advanced HF. This is different from adults in many respects, including HF etiology to overall outcomes. In this case series, we highlight characteristics and outcomes of adolescent patients managed with advanced HF therapies (ventricular assist devices (VAD) and/or heart transplant (HT)). Methods We present data of 10 consecutive patients under the age of 20 who presented to our institution between July 2014 and December 2019. All patients initially required intensive cardiac care, subsequently they went on to receive advanced therapies. Donor scarcity mandated that some patients were referred abroad for HT. All VAD were implanted at our center. Results Table 1 outlines patient characteristics. Mean age at the time of advanced therapy was 15.2 years (range 11-19 years). Seventy percent were males and 40% had familial cardiomyopathy with mean follow 29.9± 24 months. Four patients required a VAD as bridge to transplant, with one of them currently on the waiting list. One patient was bridged to transplantation with extracorporeal membrane oxygenation support. As expected with the younger population the incidence of renal dysfunction was low as was post HT biopsy proven acute rejection (BPAR). One patient had donor transmitted coronary vascular disease and subsequently developed cardiac allograft vasculopathy eventually requiring surgical revascularization. One patient developed perioperative coagulopathy and subsequently anoxic brain injury as he was bridged from VAD to HT. He was later declared brain dead. There was one death due to severe graft failure secondary to non-compliance with medical therapy or follow up. Conclusion Advanced HF in the adolescent population presents a significant challenge to newly established HF programs. In addition to unique clinical aspects, issues like insight, compliance, and parent trust can contribute to delayed presentation and intervention. Our outcomes are comparable to high-volume centers in western countries. Patient and family education and involvement in therapy and decisions is imperative to long-term success with this age group.