Urgent LVAD implantation in children on peripheral VA-ECMO support

Background. Heart transplantation (HT) remains the primary surgical treatment for children with end-stage chronic heart failure (CHF). More than 30% of pediatric HT candidates require shortor long-term mechanical circulatory support (MCS) due to refractoriness to medical therapy. In recent years, the use of left ventricular assist device (LVAD) systems has expanded not only in teenagers and middle-aged children but also in younger and smaller patients.

Objective: to investigate the perioperative course of emergency LVAD implantation in children with critical hemodynamic compromise (INTERMACS profile I) requiring short-term MCS via peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO).

Materials and methods. We studied 25 patients under 18 years of age (12 girls, 48.0%; 13 boys, 52.0%) who had a HeartMate III LVAD LVAD implanted between January 1, 2021, and June 30, 2024. The severity of pre-implantation CHF was classified according to INTERMACS profiles: I (n = 4, 16.0%), II (n = 9, 36.0%), and III (n = 12, 48.0%). Patients were divided into two groups based on the need for VA-ECMO prior to LVAD implantation: the VA-ECMO–LVAD group (n = 4, 16.0%) and the LVAD group (n = 21, 84.0%).

Results. The VA-ECMO–LVAD group (n = 4) did not differ significantly from the LVAD group (n = 21) in age, sex, or underlying disease. Intraoperatively, there were no significant differences between groups in the duration of cardiopulmonary bypass, doses of sympathomimetic cardiotonics, or the use of inhaled nitric oxide. The VA-ECMO–LVAD group showed a trend toward greater intraoperative blood loss and transfusion requirements (p > 0.05). In the postoperative period, blood loss volumes were similar between groups. However, patients in the VA-ECMO–LVAD group more frequently required re-sternotomy (25% vs 9.5%, p < 0.05), had a longer duration of postoperative mechanical ventilation (1.79-fold, p < 0.05), more often required renal replacement therapy (2.5-fold, p = 0.166), and had significantly longer ICU stays (2.75-fold, p = 0.041). In the VA-ECMO–LVAD group, the incidence of severe acute right ventricular dysfunction was significantly higher (25.0% vs 9.5%, p = 0.016). No significant difference in postoperative hospital mortality was observed between the two groups.

Conclusion. Emergency implantation of an LVAD system in children with critical hemodynamic instability requiring preoperative short-term MCS using peripheral VA-ECMO has demonstrated high effectiveness. However, careful consideration should be given to the presence and severity of multiple organ dysfunction before and after LVAD implantation, as well as perioperative blood loss. These factors largely determine the anesthetic and resuscitative management strategies, as well as the immediate outcomes of long-term MCS.

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