Mayer Rory R, Hwang Steven W, Reddy Gaddum D, Morales David L, Whitehead William E, Curry Daniel J, Bollo Robert J, Luerssen Thomas G, Jea Andrew
Division of Pediatric Neurosurgery, Department of Neurosurgery, Texas Children’s Hospital, Baylor College of Medicine, Houston 77030, USA.
J Neurosurg Pediatr. 2012 Nov;10(5):370-5. doi: 10.3171/2012.7.PEDS12161. Epub 2012 Aug 31.
Left ventricular assist devices (LVADs) are continuous or pulsatile flow devices that could potentially be life-saving measures for patients with end-stage heart failure. These devices have clear advantages over extracorporeal membrane oxygenation (ECMO) and are often used in adults. They are only recently being commonly used in the pediatric age group. As the use of LVADs becomes more mainstream in children, it is important to determine the complication profile associated with these devices. Furthermore, with the increasing application of LVADs in children, pediatric neurosurgeons are seeing a correlative increase in associated neurological complications. In this study, the authors reviewed the incidence of neurological complications due to LVAD use in the pediatric age group and the role of neurosurgery in treatment.
The authors examined data regarding patients with LVADs from the Texas Children's Hospital Heart Center database (July 01, 2007, to June 30, 2011) and recorded neurological complications requiring neurosurgical consultation. They identified 2 children who underwent craniotomies during LVAD treatment.
Intracranial hemorrhage occurred in 3 (6.5%) of the 46 patients treated with an LVAD at the authors' institution. Of these patients, 2 were treated with craniotomies for life-threatening intracranial hemorrhages. The 3 patients in the neurosurgical cohort presented with cerebral infarction, decreased level of consciousness, and/or seizure. At the last follow-up (286, 503, and 550 days), 1 patient (case 2) had no decline in neurological status, underwent a successful heart transplant, and was discharged home; 1 patient (case 1) died of refractory cardiac failure; and 1 patient (case 3) was on an LVAD for destination therapy (that is, the LVAD is not a bridge to transplantation but rather the final treatment). This patient was discharged from the hospital, but he died of overwhelming fungemia at 286 days while on VAD support.
Intracranial hemorrhage is a serious and feared complication of LVAD treatment. While the surgical risk is substantial due to systemic anticoagulation and significant medical comorbidities, neurosurgical evacuation of hemorrhage plays an important life-saving role that can yield successful and acceptable outcomes.
左心室辅助装置（LVAD）是连续性或搏动性血流装置，对终末期心力衰竭患者可能是挽救生命的措施。这些装置相对于体外膜肺氧合（ECMO）具有明显优势，常用于成人。它们直到最近才开始在儿科年龄组中普遍使用。随着LVAD在儿童中的使用变得更加主流，确定与这些装置相关的并发症情况很重要。此外，随着LVAD在儿童中的应用越来越多，儿科神经外科医生发现相关神经并发症也相应增加。在本研究中，作者回顾了儿科年龄组中因使用LVAD导致的神经并发症发生率以及神经外科在治疗中的作用。
作者检查了德克萨斯儿童医院心脏中心数据库（2007年7月1日至2011年6月30日）中有关LVAD患者的数据，并记录了需要神经外科会诊的神经并发症。他们确定了2例在LVAD治疗期间接受开颅手术的儿童。
在作者所在机构接受LVAD治疗的46例患者中，有3例（6.5%）发生颅内出血。在这些患者中，2例因危及生命的颅内出血接受了开颅手术。神经外科队列中的3例患者表现为脑梗死、意识水平下降和/或癫痫发作。在最后一次随访时（286天、503天和550天），1例患者（病例2）神经状态无下降，成功接受心脏移植并出院回家；1例患者（病例1）死于难治性心力衰竭；1例患者（病例3）接受LVAD进行目标治疗（即LVAD不是移植的桥梁，而是最终治疗手段）。该患者出院，但在接受VAD支持286天时死于严重真菌血症。
颅内出血是LVAD治疗的一种严重且令人担忧的并发症。虽然由于全身抗凝和严重的内科合并症，手术风险很大，但神经外科手术清除出血起着重要的挽救生命的作用，可产生成功且可接受的结果。
