BACKGROUND

Durable ventricular assist devices (VADs) are increasingly used to treat children with heart failure. Studies demonstrate worse outcomes for those in cardiogenic shock at the time of VAD, but limited data exist on less acutely ill children. We describe the association between illness severity and outcomes in this population.

METHODS

Data were analyzed from 373 children (aged <19 years) receiving durable VADs from 46 centers in the Pediatric Interagency Registry for Mechanical Circulatory Support. Outcomes were compared by Interagency Registry for Mechanical Circulatory Support (INTERMACS) Patient Profile (PP) and pre-implant characteristics using competing risks methodology.

RESULTS

Analyses identified 97 patients in cardiogenic shock (PP 1), 222 with progressive decline (PP 2), and 42 stable on inotropes (PP 3). There were 39 infants, 124 were aged 1 to 9 years and 210 were aged 10 to 19 years. A majority had cardiomyopathy and 66 had congenital heart disease (CHD). There were 224 (62%) continuous-flow VADs. Before implant, 40% received mechanical ventilation (MV). Within 6 months post-implant, 57% underwent transplant and 14% died. PP 1 mortality was highest (25% vs 10% for PP 2, hazard ratio [HR]: 2.5, 95% CI: 1.4–4.4, p = 0.02). In PP 1, CHD was an independent mortality risk factor (HR: 2.9, 95% CI: 1.1–7.8, p = 0.03). In PP 2, pulsatile VADs were associated with death (HR: 3.9, 95% CI: 1.6–9.5, p = 0.003). Patients on MV had high mortality (20%–30%) across PP 1 to PP 3 (HR: 3.0 vs no MV, p < 0.001).

CONCLUSIONS

Children in shock at the time of VAD implant have poor outcomes. MV is associated with increased mortality even in lower acuity INTERMACS profiles. Further study is needed to identify modifiable risk factors in this population.

中文翻译：

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植入前疾病严重程度对使用耐用心室辅助装置的小儿患者预后的影响。

背景

耐用的心室辅助设备（VAD）越来越多地用于治疗心力衰竭的儿童。研究表明，在进行VAD时发生心源性休克的患者的预后较差，但对于病情较轻的儿童，数据有限。我们描述了该人群疾病严重程度与预后之间的关系。

方法

分析了来自儿科机械循环支持机构间登记处46个中心接受持久性VAD的373名儿童（年龄小于19岁）的数据。使用竞争性风险方法，通过机构间机械循环支持注册系统（INTERMACS）患者资料（PP）和植入前特征比较结果。

结果

分析确定了97例心源性休克（PP 1），222例进行性下降（PP 2）和42例正性肌力稳定患者（PP 3）。有39例婴儿，其中124例1到9岁，210例10到19岁。多数患有心肌病，66例患有先天性心脏病（CHD）。有224个（62％）连续流VAD。植入前，40％接受了机械通气（MV）。植入后6个月内，有57％接受了移植，而14％死亡。PP 1的死亡率最高（25％vs PP 2的10％，危险比[HR]：2.5，95％CI：1.4–4.4，p  = 0.02）。在PP 1中，冠心病是一个独立的死亡危险因素（HR：2.9，95％CI：1.1–7.8，p  = 0.03）。在PP 2中，搏动性VAD与死亡相关（HR：3.9，95％CI：1.6–9.5，p = 0.003）。MV患者在PP 1至PP 3之间的死亡率较高（20％–30％）（HR：3.0 vs无MV，p <0.001）。

结论

VAD植入时处于休克状态的儿童预后不良。即使在较低敏度的INTERMACS谱中，MV也与死亡率增加有关。需要进一步的研究来确定该人群中可改变的危险因素。