Use of a Mechanical Assist Device for Children with End-Stage Cardiomyopathy Lessens Mortality While on Heart Transplant

Mechanical assist devices for children with end-stage cardiomyopathy who are waiting for a heart transplant may minimise the number of deaths that occur among this group, according to a 5-year retrospective review of data from the paediatric transplant programme in the United Kingdom.

“A key component of the success of this programme has been the simultaneous implementation of a policy to list as urgent most paediatric patients on mechanical support for the next available matched heart,” writes Allan Pl Goldman, MRCP, Great Ormond Street Children’s Hospital, London, and colleagues. Overall, 22 children, who were a median age of 5.7 years and were treated at 1 of the 2 paediatric transplant centres in the UK, were placed on a mechanical device as a bridge to heart transplantation.

Of the 13 patients who received extracorporeal membrane oxygenation (ECMO), 1 patient died before transplant while 12 received transplants, within a median of 9 days, and survived to discharge. One patient, successfully weaned from support after 5 days, was placed back on support 18 months later and subsequently underwent transplantation. The researchers report few complications related to the peripheral cut-down ECMO cannulations. At 12.5 months follow up, all 11 of the long-term survivors remained neurologically intact and were functioning normally in a mainstream school. One patient died 18 months post-transplantation for a recurrence of giant-cell myocarditis.

Of the 9 patients placed on a paediatric paracorporeal ventricular assist device, 3 died before transplant while 6 received transplants, within a median of 6.5 days, and 5 survived to hospital discharge. Six patients required re-exploration of their chest for bleeding after insertion of the ventricular assist device, with 2 patients developing severe haemolysis and 4 requiring renal support. One patient died 6 weeks post-transplantation from rejection and multiple-organ system failure. At a median of 35 months of follow up, 3 of the 4 long-term survivors are functioning at a mainstream school.

The median waiting time for a heart transplant was 7.5 days for the 22 patients bridged to transplant with 17 placed on the urgent list, compared with a waiting time of 18.0 days for the 115 non-bridged patients with 15 placed on the urgent list.

The authors suggest that ECMO offers “the safest form of short-term bridging to transplantation with end-stage cardiomyopathy, yielding excellent survival rates.” They conclude that the introduction of a mechanical assist programme to bridge children to transplantation lessens mortality among those on the heart transplant waiting list.

Lancet 2003;362:1967-70.