Mechanical Circulatory Support in Pediatric Population: Clinical Considerations, Indications, Strategies, and Postoperative Management

Fig. 35.1
Pump output of Berlin Heart EXCOR pediatric at common clinical use. Depending on body size and patient’s needs, pump chambers of different sizes can be chosen

Table 35.1
Ventricular assist devices for long-term support in children and adolescents




Patient size

EXCOR pediatric

Berlin Heart

Paracorporeal pulsatile

>2.5 kg – adult

HeartMate II


CF, axial

>1.2 m2 BSA

HeartMate IIIa


CF, centrifugal

>1.2 m2 BSA



CF, centrifugal

>1 m2 BSA




Under investigation

CF continuous flow. The EXCOR pediatric device is the only being approved for use in children

aNot approved in patients <18 years

bMVAD: device not approved, ongoing clinical trial

35.3 Postoperative Management

Postoperative management starts in the operating room. To support the right ventricle during weaning from cardiopulmonary bypass, inhaled nitric oxide, milrinone, and epinephrine are recommended. Mechanical ventilation with normoventilation (pCO2 35–40 mmHg) and long expiratory times are helpful to lower right ventricular afterload. Transesophageal echocardiography is used to rule out inflow obstruction of the cannula, to confirm adequate unloading of the left ventricle without septal shift, and to analyze right ventricular geometry and function. If right ventricular function is severely impaired despite maximal medical therapy and optimal left ventricular pump settings, the implantation of an RVAD is mandatory. Directly after bypass the heparin effect should be completely antagonized. Initial accurate hemostasis is necessary to minimize the need for blood products and avoid volume overload of the right ventricle. Closure of the chest allows for early extubation, and medical support of right ventricular function in the intensive care unit is crucial to avoid secondary heart failure.

A standard protocol for antithrombotic therapy has been proposed [10]. Anticoagulation is withheld during the first 24 h until bleeding has completely stopped. Antithrombotic therapy is initiated with unfractionated heparin and switched to low molecular heparin in infants or warfarin in children older than 1 year of age. Dual antiplatelet therapy is introduced during the first or second week of VAD support. Due to the substantial rate of early thromboembolic events, modifications of this protocol are used in many centers. Examples of strategies to lower the adverse event rate include earlier initiation of unfractionated heparin, higher target ranges for low molecular heparin and warfarin, higher dosages of antiplatelet drugs, and introduction of a third agent. Additionally, various efforts such as timely extubation, early removal of the central lines, early enteral feeding, and early mobilization should be made to reduce the risk for adverse events such as infections or thromboembolic events.

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Nov 3, 2017 | Posted by in CARDIOLOGY | Comments Off on Mechanical Circulatory Support in Pediatric Population: Clinical Considerations, Indications, Strategies, and Postoperative Management

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