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