VAD Support of High-Risk Infants with HLHS: Comparison of Rescue VAD After Prior Palliation versus Primary VAD Insertion

Abstract

<h3>Purpose</h3> To evaluate outcomes in high-risk infants with hypoplastic left heart syndrome (HLHS) supported with the Berlin Heart Ventricular Assist Device (VAD), comparing those with rescue VAD after prior palliation vs those with primary VAD insertion. <h3>Methods</h3> We reviewed all 11 high-risk infants with HLHS who were supported with the Berlin Heart VAD at our institution. Patients are divided into two categories: bridged to decision (BTD) and bridged to transplant (BTT). Patients categorized as BTD were either status post prior palliation or had delayed referral for treatment and had cardiac failure and severe end-organ injury. Patients categorized as BTT were deemed too high risk for staged palliation and underwent primary VAD insertion along with placement of bilateral pulmonary artery bands and atrial septectomy if needed. The primary outcome was mortality. <h3>Results</h3> 11 patients were supported by the Berlin Heart EXCOR between 2012-2021. <b>BTT</b>: 64% (n=7) of the patients were categorized as BTT (median age = 20 days; median weight = 3.2 kilograms). Elevated panel reactive antibody was present. Median duration of VAD support was 101 days. 71% (n=5) in the BTT group survived to hospital discharge. All 5 (100%) were alive one year after orthotopic heart transplant. <b>BTD</b>: 36% (n=4) of the patients were categorized as BTD (median age = 121.5 days; median weight = 3.8 kilograms). Elevated panel reactive antibody was present in 50% (n = 2). Median duration of VAD support was 212 days. 50% (n=2) in the BTT group survived to hospital discharge. Zero (0%) were alive one year after orthotopic heart transplant. Additional patient data is summarized in Table 1. <h3>Conclusion</h3> Outcomes for VAD insertion in infants with HLHS and end-organ injury after failed prior palliation or delayed referral are suboptimal and not as good as outcomes after primary VAD insertion. Neonates with HLHS at high risk for staged palliation should be considered for primary VAD insertion to facilitate cardiac transplantation.