Individual center experiences in pediatric mechanical circulatory support for bridge-to-transplant and myocardial recovery

Abstract

For more than two decades mechanical circulatory support (MCS) has been applied to sustain patients with low cardiac output refractory to pharmacological treatment. The aim is to convert terminal heart failure into treatable heart disease or to bridge the patient to transplantation. As the less invasive possibility of partial circulatory support the intraaortic balloon pump (IABP) has been used extensively and successfully (7). However, its use is mainly limited to the improvement of left ventricular function. More effective support can be achieved with left ventricular (LVAD), right ventricular (RVAD) or biventricular assist devices (BVAD). The impact of these devices rises with the increasing number of patients waiting for heart transplantation as bridge-to-transplant. Therefore paracorporeal or intracorporeal mechanical ventricular assistance is frequently applied in adults either for temporary myocardial decompression or for bridge-to-transplant mostly after surgical treatment of aquired heart disease. The mode of pumping is either nonpulsatile or pulsatile. In the nonpulsatile group the greatest experience is gained with the paracorporeal centrifugal pump with overall survival rates of 25–39% (15, 16, 22). In the pulsatile group the systems of the currently inserted pumps are either pneumatic or electromechanic. Some of them are used as implantable LVADs, others as total artificial heart (TAH). The overall survival rates range from 25 to 69% (2, 4, 9, 13–16, 17, 22, 27). The duration of circulatory assistance is extending continuously with the ultimate goal of total mechanical replacement of the heart. In contrast cardiomyoplasty or muscular pumps for biomechanical support are under investigation, but need further improvement prior to wide application (1).