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. 2021 Feb;11(1):148-163.
doi: 10.21037/cdt-20-278.

Heart failure in the young: Insights into myocardial recovery with ventricular assist device support

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Heart failure in the young: Insights into myocardial recovery with ventricular assist device support

Eva Maria Javier Delmo et al. Cardiovasc Diagn Ther. 2021 Feb.

Abstract

Background: Data on ventricular unloading-promoted myocardial recovery and post-weaning outcome in children is scarce. We analyzed the weaning outcome in children with heart failure (HF) supported with ventricular assist device (VAD).

Methods: A multi-institutional data on VAD implanted in 193 children and adolescents with HF between April 1990 and November 2015 was reviewed. Among them, 25 children (mean age 3.4±3.0, range, 0.058-16.3 years, 15 females) were weaned from VAD. Etiology of HF were myocarditis (n=11), dilated cardiomyopathy (DCMP) (n=7), ischemic HF (n=3), arrhythmogenic CMP (n=1), post-correction of congenital heart disease (CHD) (n=1) and acute graft failure (n=1). Mean duration of HF before VAD implantation was 59.4±3 days.

Results: Age, duration of HF, DCMP, cardiac arrest and duration of VAD are essential clinical characteristics to delineate who may have the potential to myocardial recovery. Echocardiographic parameters pre-implantation, during the final off-pump trial and during the post-explantation follow-ups revealed that LVEF, LVEDD and relative wall thickness (RWT) showed significant differences (P<0.001) among patients stratified by outcome to assess recovery. Presently, 21 (84.0%) of the weaned patients are alive with their native hearts 1.3-19.1 years after VAD explantation. An additional weaned patient had HF recurrence 3 months post-weaning and was transplanted.

Conclusions: Post-weaning myocardial recovery and cardiac stability of children with HF from several etiologies supported with a VAD appears sustainable and durable. Young patients with short HF duration are more likely to recover. Absence of cardiac arrest, cardiac size, geometry and function may prospectively identify patients who may be likely to have myocardial recovery.

Keywords: Heart failure (HF); heart transplantation; myocardial recovery; ventricular assist devices.

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Conflict of interest statement

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure forms (available at http://dx.doi.org/10.21037/cdt-20-278). The series “Heart Failure in the Young and Old: Insights into Various Therapies” was commissioned by the editorial office without any funding or sponsorship. RH served as the unpaid Guest Editor of the series and serves as an unpaid editorial board member of Cardiovascular Diagnosis and Therapy from July 2019 to Jun 2021. The authors have no other conflicts of interest to declare.

Figures

Figure 1
Figure 1
Time-related VAD support in patients who could be weaned. All patients who recovered were weaned within 155 days after VAD implementation, except one patient who recovered after 700 days. SE, standard error; VAD, ventricular assist device.
Figure 2
Figure 2
Freedom from recurrence of heart failure in children weaned off VAD support. All weaned patients remained free from heart failure recurrence, except one with non-compaction CMP who died after 61 days. SE, standard of error; CI, confidence interval.
Figure 3
Figure 3
Cumulative survival of 25 children who had myocardial recovery showing a survival rate is 62.9%±19.4% at 19 years. SE, standard of error; CI, confidence interval.
Figure 4
Figure 4
Percent change in left ventricular end diastolic diameters of three patient groups who had VAD support: those who underwent heart transplantation, recovered and died on VAD. The differences are shown in 3 time points: shortly before VAD implantation, shortly after VAD implantation and after VAD explantation for recovery-patients and after heart transplantation for heart transplant recipients. Patients who recovered had a more pronounced early LVEDD reduction after VAD implantation than those who needed transplantation or those who died. LVEDDs of transplant heart recipients remain smaller, while the LVEDD of patients who had myocardial recovery may either increase or decrease after VAD explantation. The plots show quartiles (boxes represent percentile 25 to 75, the median is the horizontal line in the boxes, whiskers are maximal and minimal values, apart from outliers and extreme values) and individual differences. LVEDD, left ventricular end-diastolic diameter; VAD, ventricular assist device.
Figure 5
Figure 5
Stacked transition probabilities derived from multistate estimation for time-related events of children with heart failure supported with VAD. The continuous lines show the estimations, the dashed lines their confidence limits. Numbers of patients at risk in a certain state may be read from the previous figures; the model shown considers all survivors at the time shown in the x-axis. The vertical distance between a line and the line underneath shows the fraction of patients that can be expected to be in the state described in the figure at the time given on the x-axis. To find the percentage of patients that corresponds to the vertical distance, shift the distance arrow to the bottom of the y-axis on the bar top, the scale indicates the percentage of patients being in this state. For example, at 15 years about 13% of the children who needed VAD support were in the state of recovery. Risk factors for the transitions from one state to another are illustrated. State wise risk factors derived from this model are described in Table 5. VAD, ventricular assist device.

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