Left ventricular assist device support as destination therapy in pediatric patients with end-stage heart failure

The development of ventricular assist devices to sustain the circulation represents one of the great achievements in the treatment of heart failure. Though early (1st generation) pulsatile devices required that patients remain hospitalized while on support, newer 2nd and 3rd generation continuous-flow (CF) devices have allowed for hospital discharge, expanding their use beyond bridge to transplantation to include permanent support. This indication, referred to as “destination therapy” is emerging as a viable alternative to heart transplantation in adults, and more recently, children. Though no formal indications exist for destination therapy in children, it may be considered in lieu of transplantation in patients with non-cardiac life-limiting comorbidities, severe pulmonary hypertension, obesity (BMI > 35 kg/m2), recurrent malignancy, or if it is their preference. One group for whom DT may be most appropriate is those with advanced dystrophinopathies for whom post-transplant outcomes remain poor. Outpatient management of the pediatric destination therapy patient requires close monitoring by a multidisciplinary team of physicians, nurses, pharmacists, social workers, nutritionists, and psychologists. Because destination therapy in children remains quite rare, little is known about long-term outcomes in this population, though studies of children supported as outpatients as a bridge to transplantation suggest that survival is excellent and functional status improves post-implantation. As ventricular assist devices continue to develop, the future will not only include application of this technology to a more diverse group of patients, but the additional challenge of supporting patients for increasingly longer durations, managing late complications, and facilitating improvements in quality of life.