LVAD Implantation in Pediatric Population
LVAD Implantation in Pediatric Population inflow from LV and outflow to Ascending Aorta.
LVAD Implantation in the Pediatric Population
By Sam Zeraatiannejaddavani, MD
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A — Assessment & Indications
1. Clinical Indications
•Refractory Stage D heart failure despite optimal medical therapy (NYHA IV / INTERMACS 1–4).
•Bridge to transplant (BTT) or Destination Therapy (DT) in select pediatric patients.
•Bridge to recovery in potentially reversible myocarditis/cardiomyopathy.
2. Preoperative Evaluation
•Detailed history and physical exam.
•Baseline labs: CBC, CMP, coagulation profile, lactate, BNP.
•Echocardiography: LV size/function, valve pathology, RV function.
•Hemodynamic assessment: Cardiac catheterization as needed.
•Pulmonary vascular resistance (PVR) evaluation.
•Evaluate size constraints (weight/BSA) for device selection.
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B — Backup Planning & Team Roles
1. Core Team
•Pediatric cardiac surgeon
•Heart failure cardiologist
•Anesthesiologist
•Perfusionist
•ICU team (nurses, PT/OT)
•Transplant coordinator
2. ECMO/VAD Backup
•ECMO standby for intraoperative instability.
•Plan for RVAD support if RV failure develops.
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C — Counseling & Consent
•Risk/benefit discussion with family.
•Expected outcomes: survival, quality of life, transplant likelihood.
•Anticoagulation and bleeding risks.
•Potential for neurologic/event complications.
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D — Device Selection
Common Pediatric LVADs
•Berlin Heart EXCOR — paracorporeal pulsatile VAD for infants/small children.
•HeartMate 3 — intracorporeal continuous-flow for larger children/adolescents.
•HVAD (limited pediatric use; availability variable).
Selection Considerations
•Size/weight — smallest body habitus devices first.
•Ventricular anatomy.
•Anticipated support duration.
•Institutional experience.
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E — Echocardiography
•Post-implant baseline for pump settings.
•Evaluate septal position, aortic valve opening, RV size/function.
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F — Flow Dynamics & Hemodynamics
•Optimize pump speed to balance LV unloading and RV function.
•Avoid suction events.
•Maintain adequate preload and afterload.
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G — Graft & Cannula Considerations
•Precise cannula length based on anatomy.
•Secure fixation to minimize migration.
•Avoid obstruction by septum or trabeculae.
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H — Hemostasis & Anticoagulation
1. Intraoperative
•Reverse heparin appropriately post-CPB.
•Meticulous surgical hemostasis.
2. Postoperative
•Initiate anticoagulation per protocol (typically heparin transitioning to warfarin/antiplatelets).
•Monitor ACT, aPTT, INR, antiplatelet assays.
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I — Infection Control
•Antibiotic prophylaxis perioperatively.
•Sterile care of driveline exit.
•Early identification of sepsis and exit-site infections.
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J — Junction of Systems
•Close coordination between surgical, cardiology, perfusion, ICU, and rehab services.
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K — Key Monitoring Parameters
•Vital signs, including perfusion markers.
•Pump parameters (flow, speed, power, pulsatility index).
•Labs: lactate, end-organ function.
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L — Low Cardiac Output / RV Failure Management
•Optimize preload.
•Inotropes (milrinone, dobutamine).
•Pulmonary vasodilators (iNO, sildenafil).
•Consider RVAD if refractory.
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M — Mechanical Support Alternatives
•ECMO if acute decompensation prevents safe LVAD placement.
•Temporary VADs (centrifugal flows) while planning definitive support.
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N — Nutrition
•Early enteral feeding.
•Caloric optimization for growth.
•Address protein and micronutrient needs.
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O — Outcomes & Prognosis
•Pediatric LVAD improves survival to transplant and quality of life.
•Risks: bleeding, stroke, infection, pump thrombosis.
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P — Postoperative Care
•ICU: ventilator weaning, sedation management.
•Regular imaging: chest X-rays, echocardiograms.
•Early mobilization.
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Q — Quality of Life & Rehabilitation
•Physical therapy to increase strength.
•Psychological support for patient/family.
•School integration planning.
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R — Risks & Complications
Major Risks
•Bleeding
•Thromboembolism
•Stroke
•Infection
•RV failure
•Device malfunction
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S — Surveillance & Follow-Up
•Weekly to monthly clinic visits.
•Coagulation panels
•Pump parameter logs
•Imaging to assess heart recovery or complications.
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T — Transplant Considerations
•LVAD as bridge to transplant requires:
•Sensitization monitoring (PRA/DSA).
•Ongoing allocation assessments.
•Optimization to maximize transplant candidacy.
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U — Utilization Metrics
•INTERMACS profiles influence timing/outcome.
•Registry data (e.g., PediMACS) guides practice.
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V — Ventricular & Valve Considerations
•Address significant valve regurgitation/stenosis at implant.
•Aortic valve opening frequency tailored to avoid stasis.
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W — Weaning & Explantation
•Only if myocardial recovery documented.
•Gradual reduction in support with frequent echo/hemodynamic assessment.
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X — eXpanded Indications & Research
•Ongoing pediatric trials evaluating smaller continuous-flow devices.
•Investigational strategies for myocardial recovery.
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Y — Yearly Reassessment
•Growth and size re-evaluation for device fit.
•Change in pump parameters as child grows.
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Z — Zero Harm Philosophy
•Protocolized care bundles.
•Team checklists.
•Proactive complication prevention.
Dr.Sam Zeraatian Nejad Davani,Cardiovascular and Transplant surgeon. Advanced Fellow of Thoracic Organs Transplantation Chicago Illinois.