Developmental hemostasis and ventricular assist devices: A troubled relationship

Children maintain balanced hemostasis despite many hemostatic differences in comparison to adults with the incidence of thrombosis and hemorrhage in normal children being diminutive. However, there are cohorts of children demonstrated to be a high-risk for thrombosis, which specifically include children with a ventricular assist device (VAD). Adult studies demonstrate that the addition of a VAD to the circulatory system results in hemostatic activation, which unless modulated by antithrombotic therapy (AT), may result in stroke, pump thrombosis, and possibly death. Similar morbidities occur in children with a VAD and with higher incidences [1-5]; yet few studies exist to guide safe and effective AT [2,6,7]. The effect of developmental hemostasis [8,9] and drug metabolism in the presence of a VAD in infants and children are largely unknown. Developmental differences preclude the use of adult guidelines and may predispose children to morbidity and/or mortality. Studies are urgently required to understand the interface between VADs and developmental differences, especially hemostasis.