Home Is Where the HeartWare Is: Preparing Pediatric Patients and Caregivers for Discharge to Home and Integration Into the Community.

The Cardiac Center at The Children's Hospital of Philadelphia has cared for patients with implanted ventricular assist device (VAD) technology since 1998. Historically, patients requiring VAD support were managed exclusively in the Cardiac Intensive Care Unit with the first medically stable transition to the Cardiac Care Unit (step-down) taking place in 2001. Patient management was confined to the inpatient setting, as the primary device used at the time was paracorporeal and not suitable for home use. Continuous-flow devices, such as the HeartWare HVAD, have gained popularity because of miniaturized size and lower profiles of side effects and adverse events, making them more suitable for home use. This article describes a single-center experience with transitioning the VAD-supported pediatric patient to the outpatient setting, highlighting outcomes, strategies, and lessons learned in order to support VAD patients and their caregivers in the hospital and community setting.

Systemic Atrioventricular Valve Excision and Ventricular Assist Devices in Pediatric Patients.

BACKGROUND: Continuous-flow ventricular assist devices (CF VADs) designed for adults are increasingly used in pediatric patients. However, there is greater risk of device inflow obstruction as a result of size and anatomy. METHODS: We reviewed all cases of systemic atrioventricular valve (AVV) excision with HeartWare HVAD (HeartWare, Framingham, MA) implantation in the systemic ventricle performed at our institution from November 2015 to May 2016. RESULTS: AVV excision with CF VAD implantation was undertaken in 3 patients. Patient 1 was palliated in infancy, resulting in biventricular physiology with a systemic right ventricle, and presented at age 15 years with worsening ventricular dysfunction. After CF VAD implantation in the systemic ventricle and discharge to home, tricuspid valve obstruction to VAD inflow developed, and the patient and underwent tricuspid valve excision on postoperative day 52. Patients 2 and 3 were aged younger than 4 years, with a body surface area of 0.62 m2 and 0.58 m2, respectively, and had undergone Fontan palliation, with subsequent systemic ventricular dysfunction and AVV regurgitation. In both Fontan patients, the CF VAD was implanted in the right atrium with simultaneous excision of the AVV. None have had evidence of elevated atrial pressures or recalcitrant pulmonary edema. At a mean follow-up of 359 days (range, 304 to 422 days), there have been no concerns for inflow obstruction or low flow. CONCLUSIONS: CF VAD implantation with AVV excision can successfully support complex pediatric patients in a wide range of size and anatomy (small chambers, systemic right ventricles). This technique may allow for CF VAD implantation in patients previously deemed too small for such support.