Why Children Are Not Small Adults? Treatment of Pediatric Patients Needing Mechanical Circulatory Support
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1 Why Children Are Not Small Adults? Treatment of Pediatric Patients Needing Mechanical Circulatory Support Utpal S Bhalala, MD, FAAP Assistant Professor and Director of Research Pediatric Critical Care Medicine Associate Medical Director, Volker Clinical Research Center The Children s Hospital of San Antonio Baylor College of Medicine
2 No Disclosures to Report
3 Learning Objectives 1. Learn why children are not little adults 2. Compare and contrast the differences between mechanical circulatory support in adults and pediatrics with advanced cardiovascular disease 3. Discuss novel treatment modalities for pediatric patients with advanced heart disease
4 Not within the scope of this talk -Timing of Mechanical Circulatory Support (MCS) in relation to cardiac failure -Practical perks while managing patients on MCS -Anticoagulation management of patients supported on MCS -Serious infectious complications of MCS and management of infections -Ethical and social considerations -Withdrawal of life support considerations for children supported on MCS
5 Why Children Are Not Small Adults?
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16 Pediatric Heart Failure
17 Pediatric Heart Failure - In contrast to adults with HF, children with HF vary in size, anatomy (congenital heart disease), and total number. - As the pediatric population living with HF expands, increasing demands on alternatives to ECMO have arisen. - These factors pose significant technological and financial concerns on the development of alternative forms of Mechanical Circulatory Support (MCS) for children with HF.
18 Pediatric Heart Failure - Mechanical Circulatory Support (MCS) is the use of a mechanical pump/s to support a weakened heart muscle. - Ventricular Assist Device (VAD) to assist a weakened ventricle - Total Artifical Heart (TAH) to replace biventricular failing heart
19 Mechanical Circulatory Support (MCS) - Mechanical Circulatory Support (MCS) can be used in the following roles: - Bridge to Transplant (BTT) - Bridge to Recovery (BTR) - Bridge to Decision/Candidacy (BTD) - Chronic Therapy
20 ECMO
21 ECMO
22 ECMO
23 Adult Mechanical Circulatory Support (MCS)
24 EXCOR Berlin Heart - Uni - or Bi- Ventricular Support - Longest application > 1000 days - Wide selection of blood pumps and cannulas - Specially designed small pumps and cannulas for infants and children - Easy visual inspection of the blood pumps (pump performance and/or deposit formation) - Paracorporeal design allows for ease of exchange due to upsize or thrombus
25 EXCOR Berlin Heart
26 EXCOR Berlin Heart EXCOR Ikus Driving Unit Electro pneumatic driving unit Suitable for all EXCOR blood pumps Uni- and biventricular operation Battery back-up Hand pump provided for emergency use Various operating modes for BVAD support
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28 EXCOR Berlin Heart - EXCOR Berlin Heart IDE study led to FDA approval of the device in U.S.A. on December 16, Although this study showed a significant mortality benefit, significant morbidity remained - Bleeding 44% - Stroke 29%
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30 44% BTR 67% ECMO Survival 80% VAD Survival Wilmot et al. J Car Fail. 2011
31 TandemHeart Percutaneous placed short-term LVAD Courtesy of Cardiac Assist Inc, Pittsburg, PA
32 HeartMate II LVAD Surgically placed long-term LVAD Battery pack External console
33 Pediatric MCS - Increasing literature reports show promising VAD results in the pediatric HF population. - In the setting of limited heart transplant donors, and increasing numbers of children with HF, many centers are utilizing VAD s as a bridge to transplant (BTT). Chen et al. Eur J Cardiothorac Surg 2005 Lorts et al. Curr Opin Organ Transplant 2015
34 Increased Number of Participating Centers in PediMACS Blume et al-aha 2014
35 ISHLT BTT with MCS ( )
36 Pediatric MCS - With the increased utilization of MCS in the pediatric HF population, the ISHLT recently released updated Guidelines for the Management of Pediatric HF in These guidelines include MCS use in the pediatric HF population including indications for MCS, patient selection, timing of implant, device selection, and recommendations. ISHLT Guidelines for the Management of Pediatric Heart Failure, 2014
37 Pediatric MCS - MCS is reserved for children with acute lifethreatening cardiovascular events or severe HF symptoms despite maximal medical therapy. - MCS should be considered if a child requires inotropic infusions to maintain cardiovascular stability and other organ systems begin to be compromised. ISHLT Guidelines for Management of Pediatric Heart Failure, 2014
38 Special Pediatric MCS Considerations - An increased interest in chronic therapy for pediatric patients - Muscular dystrophy - Cancer patients post chemotherapy - Patients with contraindications to transplant (elevated pulmonary vascular resistance)
39 Conclusions - Although children with HF refractory to medical therapy have limited options, recent advances in MCS can provide superior outcomes when used as a bridge to transplant (BTT). - The Berlin Heart EXCOR VAD provide a MCS option for both infants and children, however morbidity concerns remain. - MCS can be used successfully as a bridge to transplant (BTT), bridge to recovery (BTR), and bridge to decision (BTD).
40 Conclusions ISHLT Guidelines for the Management of Pediatric HF include indications for MCS, patient selection, timing of implant, device selection, and recommendations. - There is an increasing interest in MCS as a chronic therapy in pediatrics. - The future of MCS in children appears promising with increasing options available in this vulnerable population
41 Learning Assessment Question 1 What is the most important mechanism by which children improve their cardiac output in contrast to adults? A) Increase in hear rate B) Increase in stroke volume C) A and B D) Neither A not B
42 Learning Assessment Question 2 Duration of CPR prior to ECPR is an important determinant of outcomes of ECPR? A) True B) False
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44 Thank You!
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