Paracorporeal continuous-flow ventricular assist devices (cfVADs) for children less than 20 kg: Challenging the paradigm in the smallest patients.

Abstract

Small children with heart failure are at high risk for waitlist mortality, experience high complication rates on ventricular assist devices (VADs), and remain the only population not routinely supported with continuous-flow ventricular assist devices (cfVADs). We sought to describe the clinical course and outcomes of an exclusively cfVAD strategy in the management of small children with heart failure. This was a retrospective review of all patients less than 20 kg supported on paracorporeal VADs at a single institution (2017-2024), stratified by univentricular versus biventricular physiology pre-VAD. Outcomes after VAD implantation, including Advanced Cardiac Therapies Improving Outcomes Network-defined serious adverse events, competing risks, and successful support (survival to transplant or 180 days of support, or alive on support at study end), were assessed. Sixty-three patients were supported on paracorporeal cfVADs. Presupport extracorporeal membrane oxygenation was common (22, 34.9%). Median days of support was 74 days (interquartile range, 32-133 days, maximum 811 days). Successful support was achieved in 52 (82.5%) patients (univentricular: 21 [70%]; biventricular: 31 [93.9%]; P = .01). Strokes occurred in 10 patients (15.9%) at a rate of 0.7 per patient-year of support. Outcomes were similar in patients less than 5 kg (n = 25, stroke: 16%, primary end-point success: 84.0%). An entirely cfVAD strategy, including predominantly paracorporeal cfVADs, in small patients less than 20 kg achieves excellent results, including high rates of successful support and low rates of hemorrhagic and neurologic complications. These results should challenge the current paradigm of using pulsatile VADs, especially in small patients.