technologic advancements in pediatric mechanical ... · technologic advancements in pediatric...
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Technologic advancements in pediatric mechanical
circulatory support
George E. Sarris, MD, PhDFACC, FACS, FAHA, FCTS, FETCS
Athens Heart Surgery InstituteIaso Children’s Hospital
Athens Greece
Athens, June 10, 2016
Outcomes of Children Bridged to Heart TransplantationWith Ventricular Assist Devices
A Multi-Institutional Study(Circulation. 2006;113:2313-2319.)
• Conclusions
• VAD support in children successfully bridged 77% of patients to transplantation, with post-transplantation outcomes comparable to those not requiring VAD.
• Risk factors: young age, congenital heart disease
Pediatric heart transplant waiting list mortality in the era of ventricular assist devices
Zafar et al, JHLT 2015:34:82–88
• CONCLUSIONS: Despite an increase in the number of children listed as Status 1A, there was more than a 50% reduction in waiting list mortality in the new era. Irrespective of other factors, patients supported with a VAD were 4 times more likely to survive to transplant.
Waiting list survival for different groups by era and ventricular assist device (VAD) use.
Multivariate analysis of risk factors for waiting list mortality.
Berlin Heart ExcorThe standard therapy for pediatric severe heart failure
over last decade
Increasing use of VADs for temporary mechanical support
Pediatric Interagency Registry for Mechanically Assisted Circulatory Support
Lorts et al ISHLT 2016
TCH temporary VAD experience (1998-2016) (Iki Adachi, AATS 2016)
Rational for VAD cardiac support (if lungs OK)
Is VAD support better than ECMO?No direct comparative data
Indirect outcome comparison TCH vs ELSO
Increasing use of Continuous Flow VADs
Increasaing use of long term CF VADs(Iki Adachi, AATS 2016)
Adult Continuous Flow VAd in ChildrenBerlin Heart Pump Chart
ThoratecHeart Mate II
Adult Continuous Flow VAD in ChildrenBerlin Heart Pump Chart
HeartWareHVAD
Clear trend for HeartWare HVAD use
Technical caveat:acute inflow angle pump thrombosis
Technical point : apical coring and inflow cannula alignment
Adachi et al, JHLT 2015:34:134-136
Standard Intrapericardial vssubdiaphragmatic pocket (TCH)
Benefits of extended VAD support
Myocardial recovery is low probability
A new era: Use of an intracorporeal systemic ventricular assist device to support a patient with a failing Fontan circulation
Morales et al, JTCVS 2011, 1423):e138-e140
The patient was discharged home and underwent successful transplant at 72 days of support.
CF VADs for systemic single ventricle support
Completing a Fontan with VAD support
Other options for supporting the failing Fontan
Systemic venous support
Paracorporeal bi -VAD
Intracorporeal bi-VAD
Total cardiac replacement
Selection of type of support
Systemic VAD with fenestration(Wash Un)
Upcoming technologies
AATS 2016
2004: NHLBI Program: Experimental support systems for children < 5 yrs age
4 VADs, 1 compact ECMO system
2010: NHLBI: PumpKIN program2 VADs, 2 compact ECMO
2012: One system left in PumkinProgram
Infant Jarvik 2015under testing and analysis
Jarvik 2015: lower rpm (hemolysis)
more flow
Expected PumKIN program timeline
Studies planned
Clinical sites in USA
Summary of Pumkin Program
Conclusions
• VAD use for temporary support increasing
• CF VAD use increasing
• Extended VAD Support
– improves candidacy for transplant
– Provides opportunity to assess possible myocardial recovery
• VAD support for CHD, particularly univentricular physiology will increase
Conclusions 2
• The PumKIN program’s Jarvik 2015 shows promise as a new CF Pediatric VAD