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Extracorporeal Membrane Oxygenation Versus Counterpulsatile, Pulsatile, and Continuous Left Ventricular Unloading for Pediatric Mechanical Circulatory Support*

Bartoli, Carlo R. MD, PhD1,2; Koenig, Steven C. PhD3,4,5; Ionan, Constantine MD3,5; Gillars, Kevin J. MS3; Mitchell, Mike E. MD3,5; Austin, Erle H. III MD3,5; Gray, Laman A. MD3,5; Pantalos, George M. PhD3,4,5

Pediatric Critical Care Medicine: November 2013 - Volume 14 - Issue 9 - p e424–e437
doi: 10.1097/PCC.0b013e3182a551b0
Online Laboratory Investigation

Objectives: Despite progress with adult ventricular assist devices, limited options exist to support pediatric patients with life-threatening heart disease. Extracorporeal membrane oxygenation remains the clinical standard. To characterize (patho)physiologic responses to different modes of mechanical unloading of the failing pediatric heart, extracorporeal membrane oxygenation was compared to intra-aortic balloon pump, pulsatile-flow ventricular assist device, or continuous-flow ventricular assist device support in a pediatric heart failure model.

Design: Experimental.

Setting: Large animal laboratory operating room.

Subjects: Yorkshire piglets (n = 47; 11.7 ± 2.6 kg).

Interventions: In piglets with coronary ligation-induced cardiac dysfunction, mechanical circulatory support devices were implanted and studied during maximum support.

Measurements and Main Results: Left ventricular, right ventricular, coronary, carotid, systemic arterial, and pulmonary arterial hemodynamics were measured with pressure and flow transducers. Myocardial oxygen consumption and total-body oxygen consumption were calculated from arterial, venous, and coronary sinus blood sampling. Blood flow was measured in 17 organs with microspheres. Paired Student t tests compared baseline and heart failure conditions. One-way repeated-measures analysis of variance compared heart failure, device support mode(s), and extracorporeal membrane oxygenation. Statistically significant (p < 0.05) findings included 1) an improved left ventricular blood supply/demand ratio during pulsatile-flow ventricular assist device, continuous-flow ventricular assist device, and extracorporeal membrane oxygenation but not intra-aortic balloon pump support, 2) an improved global myocardial blood supply/demand ratio during pulsatile-flow ventricular assist device and continuous-flow ventricular assist device but not intra-aortic balloon pump or extracorporeal membrane oxygenation support, and 3) diminished pulsatility during extracorporeal membrane oxygenation and continuous-flow ventricular assist device but not intra-aortic balloon pump and pulsatile-flow ventricular assist device support. A profile of systems-based responses was established for each type of support.

Conclusions: Each type of pediatric ventricular assist device provided hemodynamic support by unloading the heart with a different mechanism that created a unique profile of physiological changes. These data contribute novel, clinically relevant insight into pediatric mechanical circulatory support and establish an important resource for pediatric device development and patient selection.

1Division of Cardiovascular Surgery, University of Pennsylvania, PA.

2MD/PhD Program, University of Louisville School of Medicine, Louisville, KY.

3Cardiovascular Innovation Institute, University of Louisville, Louisville, KY.

4Department of Bioengineering, University of Louisville, Louisville, KY.

5Department of Surgery, University of Louisville, Louisville, KY.

* See also p. 910.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/pccmjournal).

Supported, in part, by grants from the National Heart, Lung, and Blood Institute (1-R01-HL61696), Jewish Hospital Research Foundation (Louisville, KY), and Kosair Charities Pediatric Heart Research Laboratory (Louisville, KY). Terumo Medical Corporation (Somerset, NJ) donated the oxygenators. Medtronic Bio-medicus Corporation (Minneapolis, MN) donated the continuous-flow blood pumps, console, and ECMO cannulae. The Cardiac Assist Division of Datascope Corporation (Fairfield, NJ) donated the intra-aortic balloon pump catheters and console used in this study.

Drs. Bartoli, Koenig, and Pantalos received funding from NIH. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: gmpant02@louisville.edu

©2013The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies