Compassionate Deactivation of Pediatric Ventricular Assist Device Support: Lessons Learned from Our First 14 Cases

Abstract

Purpose Compassionate deactivation (CD) of ventricular assist device (VAD) support is a recognized option for children when the burden of ongoing therapy outweighs the benefits. The circumstances, indications, and outcomes of CD in pediatric VAD patients are insufficiently described. Methods Review of all cases of CD at our institution between 2011-2020. To distinguish CD of VAD from other situations where VAD support is discontinued, deactivations occurring after myocardial recovery, brain or cardiac death or while also on ECMO, were excluded. Results are presented descriptively. Results Of 24 deaths on VAD, 14 (58%) were CD. Median age was 5.7 (0.6, 11.6) years; 7 (50%) had congenital heart disease; 4 (29%) were on a “dischargeable” device. CD occurred after 40 (IQR: 26, 75) days of support, none while active transplant candidates. CD discussions were initiated by the patient/parent/caregiver in 6 (43%) cases, the remainder by a medical provider ( Table ). Reasons for CD were multifactorial, and included stroke, end-organ injury, and loss of transplant candidacy. ( Figure ). CD occurred with endotracheal extubation in 12(86%) cases, and death occurred within 10 (IQR: 4, 23) minutes of CD. Conclusion CD is the mode of death in more than half of our VAD non-survivors, and is chosen for reasons mainly related to noncardiac events. Patients, caregivers, and providers may initiate CD discussions. Ventilatory support is often withdrawn at time of CD with ensuing death.