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Comparison of Transplant Waitlist Outcomes for Pediatric Candidates Supported by Ventricular Assist Devices Versus Medical Therapy

Law, Sabrina P. MD1; Oron, Assaf P. PhD2; Kemna, Mariska S. MD3; Albers, Erin L. MD3; McMullan, D. Michael MD3; Chen, Jonathan M. MD3; Law, Yuk M. MD3

Pediatric Critical Care Medicine: May 2018 - Volume 19 - Issue 5 - p 442-450
doi: 10.1097/PCC.0000000000001503
Cardiac Intensive Care
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Objectives: Ventricular assist devices have gained popularity in the management of refractory heart failure in children listed for heart transplantation. Our primary aim was to compare the composite endpoint of all-cause pretransplant mortality and loss of transplant eligibility in children who were treated with a ventricular assist device versus a medically managed cohort.

Design: This was a retrospective cohort analysis.

Settings: Data were obtained from the Scientific Registry of Transplant Recipients.

Patients: The at-risk population (n = 1,380) was less than 18 years old, either on a ventricular assist device (605 cases) or an equivalent-severity, intensively medically treated group (referred to as MED, 775 cases).

Interventions: None.

Measurements and Main Results: The impact of ventricular assist devices was estimated via Cox proportional hazards regression (hazard ratio), dichotomizing 1-year outcomes to “poor” (22%: 193 deaths, 114 too sick) versus all others (940 successful transplants, 41 too healthy, 90 censored), while adjusting for conventional risk factors. Among children 0–12 months old, ventricular assist device was associated with a higher risk of poor outcomes (hazard ratio, 2.1; 95% CI, 1.5–3.0; p < 0.001). By contrast, ventricular assist device was associated with improved outcomes for ages 12–18 (hazard ratio, 0.3; 95% CI, 0.1–0.7; p = 0.003). For candidates 1–5 and 6–11 years old, there were no differences in outcomes between the ventricular assist device and MED groups (hazard ratio, 0.8 and 1.0, p = 0.43 and 0.9). The interaction between ventricular assist devices and age group was strongly significant (p < 0.001).

Conclusions: This is a comparative study of ventricular assist devices versus medical therapy in children. Age is a significant modulator of waitlist outcomes for children with end-stage heart failure supported by ventricular assist device, with the impact of ventricular assist devices being more beneficial in adolescents.

1Division of Pediatric Cardiology, NewYork Presbyterian/Morgan Stanley Children’s Hospital, Columbia University Medical Center, New York, NY.

2Epidemiology, Institute for Disease Modeling, Seattle, WA.

3Department of Pediatrics, Seattle Children’s Hospital, Seattle, WA.

*See also p. 498.

The data reported here have been supplied by the Minneapolis Medical Research Foundation, as the contractor for Scientific Registry of Transplant Recipient. The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as an official policy of or interpretation by the Scientific Registry of Transplant Recipient or the U.S. government. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Supported, in part, by Institutional departmental funding made available from the Cardiology Faculty Research Fund at Seattle Children’s Hospital, Seattle, WA.

Dr. Law received support for article research from Cardiology Faculty Research Fund. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Address requests for reprints to: Sabrina P. Law, MD, NewYork Presbyterian/Morgan Stanley Children’s Hospital, Columbia University Medical Center, 3959 Broadway, 229 North, New York, NY 10032. E-mail: sl3118@cumc.columbia.edu

Copyright © 2018 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies