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Temporary Circulatory Support in Children Awaiting Transplant
Study Questions:
In pediatric patients, is temporary circulatory support (TCS) superior to extracorporeal membrane oxygenation (ECMO) as a bridge to heart transplant?
Methods:
All patients ≤21 years of age listed for heart transplant between January 2011 and December 2015 supported on ECMO or TCS were identified using data from the Organ Procurement and Transplant Network (OPTN). Children supported with a TCS device were compared to a propensity score-matched cohort of children supported with ECMO as a bridge to transplant. The primary endpoint was survival to transplant.
Results:
During the study period, 371 patients were supported with ECMO (n = 278) or TCS (n = 93). A majority (59%) had left ventricular assist devices, while 23% had right ventricular assist devices and 18% had biventricular assist devices. There was a significant increase in the use of TCS over the course of the study period. The most commonly used device was the CentriMag-PediMag system (65%) followed by TandemHeart (18%), Rotaflow (6%), and Impella (5%). For propensity score-matched patients, support duration was longer for TCS patients (median 19 vs. 6 days, p < 0.001). Compared to the ECMO cohort, the propensity score-matched TCS cohort had longer survival to transplant (hazard ratio [HR], 2.0; 95% confidence interval [CI], 1.3-3.3) and longer overall survival (HR, 1.6; 95% CI, 1.04-2.6).
Conclusions:
The use of TCS as a bridge to heart transplant has increased significantly in recent years, led by the growth of magnetically levitated centrifugal flow pumps. TCS durations are longer with higher patient survival as compared with ECMO.
Perspective:
This registry-based study examined the outcomes of various TCS devices as compared with conventional ECMO for infants and children requiring mechanical circulatory support. Patients with TCS devices had longer survival to transplant as compared with patients on ECMO. Although rigorous propensity score matching was performed, one cannot rule out the presence of unmeasured confounders. Additionally, there may be some variability between centers, with some centers better at ECMO and some centers better with assist devices. This study shows an important role for TCS devices in bridging pediatric patients to heart transplant.
Keywords: Extracorporeal Membrane Oxygenation, Heart-Assist Devices, Heart Failure, Heart Transplantation, Propensity Score, Tissue and Organ Procurement, Pediatrics, Survival, Transplants
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