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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Article info
Publication history
Published online: November 04, 2019
Accepted:
October 14,
2019
Received:
August 5,
2019
Footnotes
See page 221 for disclosure information.
Identification
Copyright
© 2019 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
