Chapter 16 / Heart Disease in the Child 255
ischemia, unintended insertion of the device into the mesenteric artery, sepsis, and
thrombocytopenia.
LVAD and RVAD
The LVADs and RVADs have not been used often in pediatric patients. This results
both from the limited availability of devices of appropriate size for small patients and,
as noted earlier, because infants and children usually have combined right and left ven-
tricular and, frequently, pulmonary failure. An intraoperative algorithm was developed
by Karl et al. (52) to determine if the child could be supported with a VAD or if an
ECMO system would be necessary. While still using cardiopulmonary bypass, a
venous return cannula is inserted into the left atrium and the right atrial venous return
cannula is clamped, essentially providing only left ventricular assistance. If, while
maintaining a flow rate of 150 mL/kg/min, the right atrial pressure remains <12 mm
Hg, the pulmonary artery systolic pressure remains one-half or less of systemic pres-
sure, and the right ventricle does not dilate, the patient is ventilated and the oxygenator
is temporarily bypassed. If, after these maneuvers, gas exchange, acid–base balance,
and hemodynamics remain stable, the patient is recannulated for VAD support; other-
wise, ECMO or BVAD is used.
Karl et al. (53) reported their experience with a centrifugal pump circuit in 12 chil-
dren aged 6 d to 12 yr. The patients were supported from 38 to 190 h. Ten patients were
weaned from support and six survived to leave the hospital.
Farrar et al. (54) used a pneumatic bellows type of ventricular assistance device as a
bridge to transplantation in 72 heart transplant candidates. These included a 12-yr-old
and a 13-yr-old child, both of whom died. Of the 14 patients who required an LVAD,
10 survived to transplantation and 9 survived after transplantation. Of the 58 patients
who required a BVAD, 54 survived to transplantation and 36 survived transplantation.
Thus, 63% of the patients survived from the time of device implant.
The results of the first 100 patients who received a Symbion Total Artificial Heart as
a bridge to cardiac transplantation were reported by Joyce et al. (55). Five of these
patients were between 11 and 20 yr of age. Thirty-two patients died while being sup-
ported and 68 survived to transplantation. Forty-seven survived at least 30 d after trans-
plantation and there were 16 late deaths. Either a stroke or transient ischemic attack
was noted in 9% of the patients. Age less than or greater than 40 yr did not affect sur-
vival, but the investigators did not report if age less than 20 yr affected outcome.
In 1995, a report from the Combined Registry for the Clinical Use of Mechanical
Ventricular Assistance Pumps and the Total Artificial Heart in Conjunction with Heart
Transplantation summarized the results of 584 patients who ranged in age from 3.9 to
64 yr (56). LVADs were used in 187 cases, RVADs in 5, BVADs in 164, and hybrid
BVADs in 37. Survival to hospital discharge was achieved in 274 (68.5%) patients.
Survival was 90.6% for LVAD, 0% for RVAD, 68.1% for BVAD, and 50% for hybrid
BVAD. Causes of death included bleeding, renal failure, respiratory failure, technical
problems, emboli, ventricular failure, infection, and transplantation problems.
Recently, Ibrahim et al. (47) reported the long-term outcome of children who were
hospital survivors of VAD support for circulatory failure. Of 11 hospital survivors, there
was only 1 late death and more than 80% of the survivors were in NYHA class I or II.
The use of the Hemopump axial flow device (which is no longer available) was
reported in 20 patients by Frazier et al. (57). Six patients survived more than 30 d after
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