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Canadian Journal of Cardiology

Destination-Therapy Ventricular Assist Device in Children: “The Future Is Now”

Published:November 04, 2019DOI:https://doi.org/10.1016/j.cjca.2019.10.033

      Abstract

      Durable ventricular assist devices (VADs) have significantly improved survival to transplantation among children with advanced stages of heart failure. The fundamental goals of VAD therapy include decreasing mortality, minimizing adverse events, and improving quality of life. As the pediatric VAD experience has evolved with reduced device related complications and improved survival, VAD therapy is being considered not only as a bridge to transplantation (BTT) but also as a bridge to decision (BTD) and as destination therapy (DT). Data regarding pediatric DT VAD are limited to anecdotal or case reports of children being supported for long periods with VADs and by default being classified as DT VAD. This article reviews current trends in the use of DT VAD and adverse events in children vs adults on VAD, and provides a framework for patient selection with the use of a multidisciplinary approach including palliative care. The general approach to determining DT VAD candidacy should include: 1) a reasonable success that the patient will survive the peri- and postoperative state; and 2) a high likelihood that the patient will be able to be discharged out of hospital and have adequate caregiver support. Patients with muscular dystrophy and failing Fontan physiology are examples of pediatric populations for whom DT VAD may be considered and which require unique considerations.

      Résumé

      Les dispositifs d’assistance ventriculaire (DAV) durables ont significativement amélioré la survie après une transplantation chez les enfants présentant une insuffisance cardiaque avancée. Les objectifs premiers de l’implantation d’un DAV sont de réduire la mortalité, d’atténuer les événements indésirables et d’améliorer la qualité de vie. Au fil de l’évolution des connaissances en matière d’implantation de DAV chez les enfants, les complications liées au dispositif ont diminué et la survie s’est améliorée, ce qui fait que le traitement par DAV est aujourd’hui considéré non seulement comme étant un pont vers la transplantation (PT) mais aussi un pont vers la décision (PD) et une option d’assistance circulatoire définitive (ACD). Les données relatives à l’implantation de DAV dans un but d’ACD chez des enfants se limitent à des anecdotes ou à des exposés de cas d’enfants qui ont reçu une assistance prolongée par DAV classée par défaut comme une ACD. Le présent article passe en revue les tendances en matière de recours à un DAV comme ACD ainsi que les événements indésirables observés chez les enfants porteurs d'un DAV par rapport aux adultes, et propose un cadre de sélection des patients reposant sur une approche multidisciplinaire, y compris les soins palliatifs. Les critères d’admissibilité généraux à une ACD par DAV devraient comprendre ce qui suit : 1) une probabilité raisonnable que le patient survive aux états périopératoire et postopératoire; et 2) une forte probabilité que le patient puisse obtenir son congé de l’hôpital et recevoir une assistance adéquate de la part d’aidants. Les enfants atteints de dystrophie musculaire ou ayant une circulation de Fontan défaillante sont de bons exemples de cas exigeant des considérations particulières où un DAV peut être envisagé comme ACD.
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