Ann Thorac Surg 2006;82:933
© 2006 The Society of Thoracic Surgeons
Original article: Cardiovascular
Invited commentary
Brian W. Duncan, MD
Children's Hospital, Cleveland Clinic, Pediatric and Congenital Heart Surgery/M41, 9500 Euclid Ave, Cleveland, OH 44195
(Email: duncanb{at}ccf.org).
The present study by Sharma and coworkers [1] describes one of the larger single center experiences using ventricular assist devices (VADs) in a pediatric population. Of the 18 patients, 13 were 11 years old or older, while 14 of the patients had a body surface area of 1.4 or greater. Mechanical circulatory support for patients in this age range has more in common with support for adult patients than with support for infants and small children. The development of successful strategies for device bridging to heart transplantation for these smallest children continues to provide the greatest challenge in pediatric mechanical circulatory support. With this in mind, the overall good results reported here reflect what would be expected for a similar young adult patient population, with less pre-existing morbidities than older patients who required VAD support treated at a leading institution in this field. Likewise, the observed morbidities were similar to those reported in the adult literature and occurred with equivalent frequency. One result of particular interest was the finding that elevated panel reactive antibody (PRA) levels in 2 of the patients had no apparent adverse impact on their outcomes. Due to the relative lack of literature regarding the PRA response to VADs in children, further investigation in a larger number of patients may be warranted, perhaps through a multi-institutional approach.
Aside from these issues, the present report is of considerable value because it adds to the relatively small number of existing reports that describe the use of VADs in children. Of particular importance, the detailed management points provided here, by a unit with considerable expertise in providing mechanical circulatory support for patients of all ages, should serve as a useful guide for any center that may only rarely encounters pediatric patients who require such support. The evolution of anticoagulation management described here should be especially helpful in this regard. Furthermore, the authors' description of which of the many available devices may be useful in various clinical settings or for a given patient age should prove valuable for pediatric practitioners who may have less experience with these devices than their adult counterparts. In many ways, mechanical circulatory support for children remains in its earliest stages of development. Continued reporting and analysis of clinical series of pediatric VAD support, particularly for the smallest children, is vital to sustain the needed growth in this field.
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References
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- Sharma MS, Webber SA, Morell VO, et al. Ventricular assist device support in children and adolescents as a bridge to heart transplantation Ann Thorac Surg 2006;82:926-933.[Abstract/Free Full Text]
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