Abstract
Ventricular assist devices (VAD) are used more in children. Safe and effective anticoagulation is required for successful management of children supported with ventricular assist devices. Developmental hemostasis, device hemocompatibility, plastic to body ratio, surgical variable techniques, lack of knowledge on pharmacokinetics of anticoagulants, and wide variability in anticoagulation protocols have all contributed to increased incidence of bleeding and thromboembolic complications. New collaborative learning networks, such as the ACTION network, provide opportunities to define best practices, optimize, and reduce anticoagulation related adverse events. ACTION was established Dec 2017. It consists of expert clinicians in heart failure, as well as researchers, parents, and patients, with goals to improve outcomes, share data, improve education and standard practice for children with heart failure (1, n.d). Changes in pediatric VAD anticoagulation strategy from using mainly heparin to DTI such as bivalirudin have helped reduce bleeding and clotting complications.
Highlights
Since FDA approval of the Belin Heart EXCOR ventricular assist device (VAD) in North America over a decade ago [1] pediatric Ventricular assist devices (VAD) use has increased with favorable reduction (>50%) in waiting list mortality and improved survival following heart transplantation [2]
Time to first device malfunction/thrombus in children was significantly better in intracorporeal devices types, than paracorporeal device types, with the paracorporeal pulsatile pumps performing significantly better than paracorporeal continuous flow devices [3]
Patients supported on intracorporeal devices are bridged with bivalirudin or unfractionated heparin to VITAMIN K ANTAGONIST (VKA), with target International Normalized Ratio (INR) goal of 2– 3.5
Summary
Since FDA approval of the Belin Heart EXCOR ventricular assist device (VAD) in North America over a decade ago [1] pediatric VAD use has increased with favorable reduction (>50%) in waiting list mortality and improved survival following heart transplantation [2]. Despite increasing VAD use, hemocompatibility related adverse event, including bleeding and thrombosis with current antithrombosis agents remain among the significant challenges in children supported on VAD [5]. Achieving optimal anticoagulation and antithrombosis in VAD patients requires a balanced control of thrombin and platelets inhibition against physiologic hemostasis. In infants and young children, achieving this balance has been challenging due to several unique physiologic factors including developmental hemostasis as originally described by Monagle et al [7]. This report summarizes these challenges and describes the current antithrombotics use in children supported with VAD
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