Invited Commentary

Abstract

The decision to use a biventricular assist device (BIVAD) versus a left ventricular assist device (LVAD) for a child awaiting transplantation remains difficult. This investigation by Zafar and colleagues [1Zafar F. Jefferies J.L. Tjossem C.J. et al.Biventricular Berlin Heart EXCOR pediatric use across the United States.Ann Thorac Surg. 2015; 99: 1328-1334Google Scholar] from the Berlin Heart EXCOR Pediatric EXCOR study reveals sobering conclusions regarding mechanical assistance in children. In essence, one-third of the patients in this study required BIVAD assistance. The demographic and clinical variables of white race, abnormal glomerular filtration rate, sites with fewer than five implants, and use of the 10-mL pump were identified as predictors of mortality in BIVAD patients. BIVAD support was not associated with improved survival in any identified subset of patients, and survival in BIVAD patients was 60% versus 80% in LVAD patients at 100 days. Although pediatric patients differ from adult patients, a similar inferior survival for BIVAD patients compared with LVAD patients exists for adults [2Cleveland Jr., J.C. Naftel D.C. Reece T.B. et al.Survival after biventricular assist device implantation: an analysis of the Interagency Registry for Mechanically Assisted Circulatory Support database.J Heart Lung Transplant. 2011; 30: 862-869Abstract Full Text Full Text PDF PubMed Scopus (123) Google Scholar]. Although one is tempted to conclude that perhaps BIVAD support should be avoided at all costs, this message is not the appropriate conclusion. As mechanical circulatory support evolves, we must continue to define which patients require BIVAD support and how we can then improve BIVAD outcomes. Clearly, the current study challenges us to question how the current pediatric BIVAD technology might change to improve BIVAD survival. Biventricular Berlin Heart EXCOR Pediatric Use Across the United StatesThe Annals of Thoracic SurgeryVol. 99Issue 4PreviewBiventricular assist device (BiVAD) support was a strong predictor of early mortality in the Berlin Heart EXCOR Pediatric investigational device exemption (IDE) study (Assess Safety and Probable Benefit of the EXCOR Pediatric Ventricular Assist Device [VAD]). In adults, it has been identified that 5% to 10% of the VAD population is benefited by BiVAD support over left ventricular assist device (LVAD) support. An analysis of the Berlin Heart study cohort was performed to characterize patients supported with BiVAD, examine risk factors of mortality in this group, and identify subsets of patients in whom BiVAD is associated with survival. Full-Text PDF