Surgical strategies for the management of end-stage heart failure in infants and children: A 15-year experience with a patient-tailored approach

Abstract

End-stage heart failure (ESHF) in pediatric age is an ongoing challenge. Heart transplantation is the final option, but its long-term outcomes are still suboptimal in children. An alternative patient-tailored surgical protocol to manage ESHF in children is described. Retrospective, single-center analysis of pediatric patients admitted to our institution between April 2004 and February 2021 for ESHF. Our current protocol is as follows: (a) Patients <1 year with isolated left ventricular dysfunction due to dilated cardiomyopathy underwent pulmonary artery banding (PAB). (b) Patients <10 years and <20 kg, who did not meet previous criteria were managed with Berlin Heart EXCOR. (c) Patients >10 years or >20 kg, underwent placement of intracorporeal Heartware. Primary outcomes were survival, transplant incidence, and postoperative adverse events. A total of 24 patients (mean age 5.3 ± 5.9 years) underwent 26 procedures: PAB in 6 patients, Berlin Heart in 11, and Heartware in 7. Two patients shifted from PAB to Berlin Heart. Overall survival at 1-year follow-up and 5-year follow-up was 78.7% (95%CI = 62%-95.4%) and 74.1% (95%CI = 56.1%-92.1%), respectively. Berlin Heart was adopted in higher-risk settings showing inferior outcomes, whereas a PAB enabled 67% of patients to avoid transplantation, with no mortality. An integrated, patient-tailored surgical strategy, comprehensive of PAB and different types of ventricular assist devices, can provide satisfactory medium-term results for bridging to transplant or recovery. The early postoperative period is critical and requires strict clinical vigilance. Selected infants can benefit from PAB that has demonstrated to be a safe bridge to recovery.

Keywords: heart transplantation; mechanical circulatory support; pediatric heart failure; pulmonary artery banding; ventricular rehabilitation.

FIGURE 1

Patient‐tailored protocol for end‐stage heart failure [Color figure can be viewed at wileyonlinelibrary.com]

FIGURE 2

Antithrombotic protocol for mechanical circulatory support devices [Color figure can be viewed at wileyonlinelibrary.com]

FIGURE 3

Kaplan–Meier plot of overall survival rate (n = 24)

FIGURE 4

Treatment flow‐chart (n = 24) [Color figure can be viewed at wileyonlinelibrary.com]

FIGURE 5

Kaplan–Meier plot of survival rate according to initial treatment (n = 24). *Of note that, although survival rate for PAB was 100%, this strategy failed in two over six patients, and these two patients survived by conventional VAD therapy