THE USE of VENTRICULAR ASSIST DEVICES in CHILDREN: CURRENT OPTIONS & FUTURE TRENDS
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1 THE USE of VENTRICULAR ASSIST DEVICES in CHILDREN: CURRENT OPTIONS & FUTURE TRENDS
2 ADULTS : VAD Better Accepted Technically easier Fewer anatomical constraints HTx is realistic possibility Overall experience
3 Farrar, Hill, Pennington et al. J. Thorac.. Cardiovasc. Surg , 113(1), p 202 Cohort of 213 pts. in 35 centres LVAD / RVAD / BiVAD or combo 58% - 75% survival (all HTx) Survival after HTx > 81%
4 CHILDREN : VAD Less Well Accepted? Technically difficult? Some anatomy unsuitable Less experience HTx less likely Defined contraindications ECMO for pulmonary dysfunction widely accepted
5 VAD or ECMO ADULTS CHILDREN
6 ...if Nil Contraindications... Then Paediatric VAD SHOULD be Successful - and MIGHT be Better Than ECMO VAD or ECMO ADULTS CHILDREN
7 VAD IS: Simpler Associated with less bleeding Associated with fewer patient complications Associated with fewer circuit complications Less expensive More children are weaned (but no more survive)
8 Indications for VAD Unweanable from CPB Weanable / weaned, but low cardiac output Low cardiac output, not related to surgery» i.e.. recovery expected Bridge to transplant» i.e.. recovery not expected
9 VAD or ECMO - that IS the question... either in OR or ICU, adequate oxygenation, no RV failure, no pulmonary hypertension Three, = VAD One X = ECMO
10 Does patient oxygenate? yes Refractory RV failure? no no ECMO ECMO yes Refractory PHT? yes no ECMO VAD
11 RCH VAD Procedure Patients Norwood operation 10 Valve repair / replacement 9 Arterial switch operation 7 ALCAPA repair 5 Konno 3 Aortic root replacement 3 Supravalvar AS repair 2 HTx / HLTx 2 Bidirectional CP shunt 2 Miscellaneous 5 SOTO et.al. 1997
12 RCH VAD Univentricular vs biventricular repair p = 0.29 Definitive vs palliative repair p = 0.29 Age < 1 year p = 0.13 Weight < 6 Kg p = 0.35 SOTO et.al. 1997
13 Berlin Heart Paracorporeal,, pneumatic 10, 25, 30 ml stroke volume Trileaflet polyurethane valves
14 Centrifugal pumps Biomedicus, Sarns-Delphin Delphin,, SJM-Lifstream Non-occlusive» Preload and afterload dependant
15 Medos / HIA Paracorporeal,, pneumatic 9, 10, 22.5, 25 ml stroke volumes 12 & 16 mm trileaflet polyurethane valves Touch-screen drive unit Transparent Seamless joints CAD optimized washout
16 Location Author Device Year No. Pt s s No. Weaned No. Disch. Texas Scheinin CP; HP Berlin Hausdorf BH Sydney Costa CP; RP Berlin Ishino BH Pittsburgh Ashton CP; ABIO Tokyo Takano TOYOBO Melb rne Soto CP Bergamo Glauber CP Boston Del Nido N/A 50 CP
17 RCH VAD experience: patients (49 procedures) Median age: 3.5 months (2 days - 19 years) Median weight 4.7 kg ( kg) 71% weaned SOTO etal 1997
18 Kormos advocates Better selection & appropriate timing NOW FUTURE ICU Discharge Organ recovery Full recovery Large device Portable / implantable Non ambulatory School / work Short term Months / years HTx ASAP HTx when optimal
19 The Future... Biomedicus use of a Cray super computer for Computational Fluid Dynamics analysis? decrease haemolysis by 25% other information confidential
20 The Future... Biomedicus - Heinrich Heine University design of servoregulation system for inlet Aim : increase safety limit effects of NVP
21 The Future... Abiomed Research into paediatric version 60 ml prime ; ml/min. flow Adjustable stroke volume 5-15 ml Status: animal experiments Issues: anticoagulation; haematology; pulsatility
22 The Future... Jarvik Axial flow 1 x 4 cm; <70 gm Flows to 3 10,000rpm Bearing design - blood washed? transcutaneous energy supply LV apex - Descending aorta Status: Animal testing Issues: power supply; thrombus
23 The Future... Pierce-Donachy Aiming for <5 kg patients Paracorporeal,, pneumatic? need to alter 10mm bileaflet valves to lessen blood trauma Improved flow patterns to facilitate» better washing» less thrombus
24 The Future... Mussivand - Univ. of Ottowa Transcutaneous energy transference Remotely programmable Totally implantable Status: prototype in animals paediatric size to come
25 The Future... Adults Univ Utah centrifugal pump Vienna Univ. sealless CP;? implantable Nimbus AxiPump Medtronic Hemopump - new smaller size (<14FR) Baylor Compact CP - uses ceramics & UHMW polyethelyne DeBakey / NASA axial flow pump
26 The Future... Adults (con( con t) Univ. Pittsburgh Artificial Heart Programme» Tiny Axial Flow pump in development
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