Mechanical bridging to orthotopic heart transplantation in children weighing less than 10kg: feasibility and limitations

Abstract

Objective: Infants and young children are considered the most difficult group to bridge to orthotopic heart transplantation (OHT) and data regarding outcomes are scarce. Methods: We reviewed our patients ≤10 kg with those who were bridged to OHT using ventricular assist device (VAD) Berlin Heart (BH) Excor ± extracorporeal membrane oxygenation (ECMO) between 2004 and 2009. Results: Eleven children ≤10 kg with end-stage heart failure (cardiomyopathy or myocarditis) were treated with VAD as bridge to OHT: the median weight was 8.0 (range 3.9–10.0 kg) kg and median age was 12.3 (range 1.2–33.9 months) months. Five (45%) required ECMO support pre-BH and six were on mechanical ventilation and inotropes. In 9/11 (82%), the support mode was left ventricular assist device (L-VAD) (all alive): one of two patients needing Bi-VAD support died. On BH, the median support time was 27 days and time to extubation was 8 days. Two out of 11 (18%) suffered strokes confirmed on brain imaging; both recovered and one underwent resection of infarcted small bowel. Ten out of 11 (91%) were transplanted, one remains in hospital and nine are at home in good health. When compared to patients >10 kg bridged with BH (n = 15), the mortality (p = 0.51) and rates of neurological complications (p = 0.54) were similar. Post-transplant recovery (ventilation times and time to home discharge) was similar between the bridged children ≤10 kg and non-bridged children ≤10 kg who underwent OHT. Conclusions: Mechanical bridging to transplantation is clinically feasible in children ≤10 kg, achieving excellent outcomes. Judicious use of VADs in smaller children will optimise the use of donor organs; however, the effect on overall OHT waiting times, if mechanical bridging was extended to a large number of small children, is unknown.