Improvement in survival after mechanical circulatory support with pneumatic pulsatile ventricular assist devices in pediatric patients
Improvement in survival after mechanical circulatory support with pneumatic pulsatile ventricular assist devices in pediatric patients
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DOI：
10.1016/j.athoracsur.2006.03.065
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发表时间：
2006-09-01
影响因子：
4.6
通讯作者：
Hennig, Ewald
中科院分区：
文献类型：
--
作者：
Hetzer, Roland;Potapov, Evgenij V.;Hennig, Ewald
背景1992年，用于婴儿和幼儿的小儿尺寸的双驱动体外心室辅助装置（VAD）被引入临床常规。在最初阶段，婴儿的结果很差。从那时起，已经引入了几个方面的改进套管，连接器，肝素涂层的血泵内表面，抗凝治疗和凝血监测，并在不可逆性休克之前，有利于泵植入的早期决策。自1990年至2005年1月1日，在我们的机构，62例柏林心脏Excor系统已植入18岁以下的患者。根据治疗阶段将患者分为两组：第1阶段，1990年至1998年期间植入器械（n = 34），第2阶段，1999年至2004年期间植入器械（n = 28）。我们比较了我们在早期和后期的经验。除支持时间（17.9 +/- 27.7天vs 53.2 +/- 83.9天，p = 0.001）外，两个阶段的术前患者数据无显著差异。在第1阶段，更多患者需要双心室VAD，而在第2阶段，更多患者使用左心室VAD进行了有效治疗（p = 0.05）。在后期，胸部可以主要关闭的婴儿比例显著较高（0%与89%，p = 0.012），更多的婴儿可以在VAD上拔管（0%与55%，p = 0.16）。在第1阶段和第2阶段，分别有35%和68%的患者在脱离系统或心脏移植后出院（p = 0.029）。在第1阶段，1岁以下儿童组无存活者，而在第2阶段，该年龄组的存活率与两组年龄较大的儿童相似（p = 0.024）。心肌病患者（43% vs 76%，p = 0.045）和心切开术后心力衰竭患者（0% vs 57%，p = 0.01）在第2阶段的出院率有显著改善。VAD的早期植入、血泵的肝素涂层以及插管设计、抗凝和凝血监测方案的实质性修改导致存活率和出院率显著增加，尤其是在1岁以下儿童中。小儿尺寸的柏林Heart Excor VAD是心源性休克儿童心脏移植或康复的重要选择。
Background. Pediatric size pneumatically driven extracorporeal ventricular assist devices ( VAD) for infants and small children were introduced into clinical routine in 1992. In the initial period, the results in infants were poor. Since then, several improvements have been introduced with regard to the cannulas, connectors, heparin coating of the blood pump inner surface, anticoagulant treatment and coagulation monitoring, and earlier decision-making in favor of pump implantation before irreversible shock has set in.Methods. Since 1990 and as of January 1, 2005, 62 Berlin Heart Excor systems have been implanted in patients below 18 years of age at our institution. The patients were divided into two groups according to the period of treatment: period 1, devices implanted between 1990 and 1998 ( n = 34), and period 2, devices implanted between 1999 and 2004 ( n = 28). We compared our experience during the earlier and later periods.Results. There were no significant differences in the preoperative patient data between the two periods except for time of support ( 17.9 +/- 27.7 days versus 53.2 +/- 83.9 days, p = 0.001). In period 1, more patients needed a biventricular VAD whereas in period 2, more patients were effectively treated with a left VAD ( p = 0.05). In the later period, the chest could be primarily closed in a significantly higher percentage of infants ( 0% versus 89%, p = 0.012), and more infants could be extubated on the VAD ( 0% versus 55%, p = 0.16). Discharge from the hospital after either weaning from the system or heart transplantation was achieved for 35% in period 1 and for 68% in period 2 ( p = 0.029). Whereas in period 1 there were no survivors in the group of children younger than 1 year old, during period 2, survival in this age group was similar to that of the two groups of older children ( p = 0.024). There was a significant improvement in the discharge rate in period 2 in patients with cardiomyopathy ( 43% versus 76%, p = 0.045) and postcardiotomy heart failure ( 0% versus 57%, p = 0.01).Conclusions. Earlier implantation of VADs, heparin coating of the blood pumps, and substantial modifications in cannula design, anticoagulation, and the coagulation monitoring regimen have led to a significant increase in the survival and discharge rate, especially among children under 1 year of age. The pediatric size Berlin Heart Excor VAD is a valuable option as a bridge to heart transplantation or recovery for children suffering from cardiogenic shock.