Department of Cardiac Surgery, Ospedale Pediatrico Bambino Gesù, Rome, Italy.
Artif Organs. 2010 Nov;34(11):1017-22. doi: 10.1111/j.1525-1594.2010.01144.x.
Despite the remarkable advances with the use of ventricular assist devices (VAD) in adults, pneumatic pulsatile support in children is still limited. We report on our experience in the pediatric population. A retrospective review of 17 consecutive children offered mechanical support with Berlin Heart as a bridge to heart transplant from February 2002 to April 2010 was conducted. The median patient age was 3.9 years (75 days to 13.3 years). The median patient weight was 14.1 kg (2.9-43kg). Before VAD implantation, all children were managed by multiple intravenous inotropes and mechanical ventilation (14) or extracorporeal membrane oxygenation (3). All patients had right ventricular dysfunction. Nine patients required biventricular mechanical support (BVAD), but in all other cases a single left ventricular assist device proved sufficient (47%). The median duration of VAD support was 47 days (1-168 days). The median pre-VAD pulmonary vascular resistance index (Rpi) was 5.7 WU/m(2) (3.5 to 14.4WU/m(2) ). Eleven patients (65%) were successfully bridged to heart transplantation after a median duration of mechanical support of 68 days (6-168 days). Six deaths occurred (35%), three for neurological complications, one for sepsis, and two others for device malfunctioning. Since 2007, the survival rate of our patients has increased from 43% to 80%, and the need for BVAD has decreased from 86% to 30%. In two patients with Rpi >10WU/m(2) , unresponsive to pulmonary vasodilatator therapy, Rpi dropped to 2.2 and 2WU/m(2) after 40 and 23 days of BVAD support, respectively. Seven patients (41%) required at least one pump change. Of 11 patients undergoing heart transplant, four developed an extremely elevated (>60%) panel reactive antibody by enzyme-linked immunosorbent assay, confirmed by Luminex. All of them experienced at least one acute episode of rejection in the first month after heart transplant, needing plasmapheresis. The survival rate after heart transplantation was 100% with a median follow-up of 25.4 months (6 days to 7.7 years). Mechanical support in children with end-stage heart failure is an effective strategy as a bridge to heart transplantation with a reasonable morbidity and mortality. BVAD support may offer an additional means to reverse extremely elevated pulmonary vascular resistance.
尽管在成人中使用心室辅助装置（VAD）取得了显著进展，但儿童的气动脉动支持仍然有限。我们报告了我们在儿科人群中的经验。对 2002 年 2 月至 2010 年 4 月期间因机械支持而接受柏林心脏作为心脏移植桥接的 17 例连续儿童患者进行了回顾性分析。中位患者年龄为 3.9 岁（75 天至 13.3 岁）。中位患者体重为 14.1kg（2.9-43kg）。在 VAD 植入前，所有儿童均接受了多种静脉内正性肌力药和机械通气（14 例）或体外膜氧合（3 例）治疗。所有患者均存在右心室功能障碍。9 例患者需要双心室机械支持（BVAD），但在所有其他情况下，单一左心室辅助装置就足以满足需要（47%）。VAD 支持的中位时间为 47 天（1-168 天）。中位 VAD 前肺血管阻力指数（Rpi）为 5.7WU/m2（3.5 至 14.4WU/m2）。11 例（65%）患者在机械支持中位时间为 68 天后成功桥接心脏移植（6-168 天）。6 例死亡（35%），3 例因神经系统并发症，1 例因脓毒症，2 例因设备故障。自 2007 年以来，我们患者的生存率从 43%增加到 80%，需要 BVAD 的比例从 86%降至 30%。在 2 例 Rpi>10WU/m2的患者中，对肺动脉扩张剂治疗无反应，分别在 40 天和 23 天后，Rpi 降至 2.2 和 2WU/m2。7 例（41%）患者需要至少一次更换泵。在接受心脏移植的 11 例患者中，4 例酶联免疫吸附试验（ELISA）检测到极高（>60%）的面板反应性抗体，通过 Luminex 得到证实。所有患者在心脏移植后第一个月都经历了至少一次急性排斥反应，需要血浆置换。心脏移植后的生存率为 100%，中位随访时间为 25.4 个月（6 天至 7.7 年）。对于终末期心力衰竭的儿童，机械支持作为心脏移植桥接是一种有效的策略，其发病率和死亡率合理。BVAD 支持可能为逆转极高的肺血管阻力提供额外手段。
