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Höhere Überlebensrate nach mechanischer Kreislaufunterstützung mittels eines pneumatischen, pulsatilen Unterstützungssystems bei Säuglingen und Kindern

Improvement in survival after mechanical circulatory support with pneumatic pulsatile ventricular assist devices in small infants and children

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Zeitschrift für Herz-,Thorax- und Gefäßchirurgie Aims and scope

Zusammenfassung

Hintergrund

Pneumatisch betriebene extrakorporale mechanische Kreislaufsunterstützungssysteme (Ventricular Assist Device—VAD) für Säuglinge und Kleinkinder wurden 1992 in die klinische Praxis eingeführt. Die anfänglichen Ergebnisse gerade bei sehr jungen Patienten waren verbesserungsbedürftig. Seit dieser Zeit sind die Systeme gerade in Bezug auf Kanülen, Konnektoren und Heparinbeschichtung des Pumpeninnenraums weiterentwickelt worden. Zusätzliche Verbesserungen wurden auch im Bereich der Durchführung und Überwachung der Antikoagulation erarbeitet, sowie im Rahmen der Patientenselektion, die nun eine den Umständen entsprechend frühe Indikationsstellung zur Implantation favorisiert, um dem Auftreten eines irreversiblen Multiorganversagens vorzubeugen.

Methoden

Zwischen 1990 und Ende 2004 wurden 62 Berlin Heart Excor-Systeme bei unter 18-jährigen Patienten in unserem Haus implantiert. Die Patienten wurden nach dem Zeitraum der Behandlung in zwei Gruppen geteilt: Zeitraum I—Implantation zwischen 1990 und 1998 (n=34) und Zeitraum II—Implantation zwischen 1999 und 2004 (n=28). Die Behandlungsergebnisse in den beiden Zeiträumen wurden verglichen.

Ergebnisse

Die präoperativen Daten der Patienten der beiden Zeiträume zeigten keine signifikanten Unterschiede. Die Unterstützungsdauer war in Gruppe II länger (17,9±27,7 vs. 53,2±83,9 Tage, p=0,001). In Gruppe I benötigten mehr Patienten ein biventrikuläres Unterstützungssystem, während in Gruppe II mehr Patienten mit einem linksventrikulären System behandelt werden konnten (p=0,05). Ein primärer Thoraxverschluss konnte in Gruppe II in signifikant höherem Maße durchgeführt werden (0 vs. 89%, p=0,012). Erst in dieser Gruppe wurde eine Extubation der Kinder während der mechanischen Unterstützung möglich (0 vs. 55%, p=0,16). In Gruppe I konnten 35% der Kinder nach Entwöhnung vom System oder Herztransplantation nach Hause entlassen werden, in Gruppe II 68% (p=0,029). In Gruppe I überlebte keines der Kinder unter einem Jahr, in Gruppe II war die Überlebensrate dieser Kinder vergleichbar mit älteren Kinder (p=0,024). Die Entlassungsrate war signifikant besser in Gruppe II bei Patienten mit Kardiomyopathie (43 vs. 76%, p=0,045) und postoperativem Herzversagen (0 vs. 57%, p=0,01).

Schlussfolgerung

Besonders bei Kindern unter einem Jahr Alter konnten über Verbesserungen am Kanülendesign, Antikoagulationsdurchführung und -überwachung signifikante Verbesserungen bei Überlebensrate und Möglichkeit zur Entlassung nach Hause erreicht werden.

Das Berlin Heart Excor-VAD ist ein zuverlässiges System, um Kindern mit kardiogenem Schock bis zur Herztransplantation oder Erhohlung der eigenen Herzfunktion zu unterstüzen.

Summary

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 cannulae, 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 used in patients below 18 years of age at our institution. The patients were divided into two groups according to the period of treatment: period I—devices implanted between 1990 and 1998 (n=34) and period II—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 vs 53.2±83.9 days, p=0.001). In period I more patients needed a biventricular VAD, whereas in period II 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 vs 89%, p=0.012) and more infants could be extubated on the VAD (0 vs 55%, p=0.16). Discharge from the hospital following either weaning from the system or heart transplantation was achieved in 35% in period I and in 68% in period II (p=0.029). Whereas in period I there were no survivors in the group of children younger than 1 year old, during period II 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 II in patients with cardiomyopathy (43 vs 76%, p=0.045) and postcardiotomy heart failure (0 vs 57%, p=0.01).

Conclusion

Earlier implantation of VADs, heparin coating of the blood pumps and substantial modifications in cannula design, anticoagulation and the coagulation monitoring regime have led to a significant increase in the survival and discharge rate, especially in 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.

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Authors and Affiliations

  1. Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 13353, Berlin, Germany

    R. Hetzer,  E. V. Potapov,  B. Stiller,  Y. Weng,  M. Hübler,  J. Lemmer,  V. Alexi-Meskishvili,  M. Redlin, F. Merkle ECCP,  F. Kaufmann &  E. Hennig

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  1. R. Hetzer
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  2. E. V. Potapov
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  3. B. Stiller
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  4. Y. Weng
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  5. M. Hübler
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  6. J. Lemmer
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  7. V. Alexi-Meskishvili
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  8. M. Redlin
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  9. F. Merkle ECCP
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  10. F. Kaufmann
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  11. E. Hennig
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Correspondence to R. Hetzer.

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Hetzer, R., Potapov, E.V., Stiller, B. et al. Höhere Überlebensrate nach mechanischer Kreislaufunterstützung mittels eines pneumatischen, pulsatilen Unterstützungssystems bei Säuglingen und Kindern. Z Herz- Thorax- Gefäßchir 19, 193–201 (2005). https://doi.org/10.1007/s00398-005-0513-1

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