ABSTRACT Background Utilization of microaxial pumps for temporary mechanical circulatory support in children has increased in recent years. However, data on patient selection, implantation techniques, and outcomes remain limited. Methods A systematic literature search was conducted in July 2025 to identify case reports and case series reporting the use of microaxial pumps in patients aged 18 years or less. Forty‐four studies comprising 100 patients were identified, and patient‐level data were extracted for analysis. Results The median age of the patients was 14 [IQR, 11.5–16] years, with a median weight of 52 [40–73] kg and median body surface area of 1.59 [1.35–1.85] m 2 . The most common diagnoses were cardiomyopathy (29%), heart allograft rejection (26%), and myocarditis (21%). Impella CP was the most frequently used device (48%), followed by Impella 2.5 and Impella 5.5 (each 21%). Access was predominantly obtained via the femoral artery (47%). Percutaneous implantation was performed in 47% of patients. Patients were weaned from microaxial support for cardiac recovery (42%) or heart transplantation (31%). Fourteen patients (14%) died prior to discharge, with significantly higher mortality among patients supported with ECPella (29%) compared with microaxial pump alone (6%; p = 0.01). The median duration of support was 6 [4–13] days. At the median follow‐up of 119 [23–180] days overall survival was 84%. Conclusion Microaxial pumps represent an important addition to temporary mechanical circulatory support in pediatric patients and can serve as an alternative to VA‐ECMO in selected cases. Outcomes were less favorable when used in tandem configurations such as ECPella, reflecting the greater severity of illness in these patients.
ABSTRACT Background Donor organ scarcity and increasing use of extended‐criteria donors have driven the development of dynamic preservation methods to improve outcomes following liver transplantation. Hypothermic machine perfusion (HMP) and normothermic machine perfusion (NMP), controlled oxygenated rewarming (COR), and ischemia‐free liver transplantation (IFLT) are dynamic preservation methods that have been compared with traditional static cold storage (SCS). However, no randomized clinical trials (RCTs) have directly compared HMP with NMP. The aim of the present study is to conduct a network meta‐analysis (NMA) of RCTs to compare the effects of available dynamic preservation strategies on clinical outcomes. Methods Electronic databases were systematically searched for RCTs evaluating dynamic preservation methods in human liver transplantation. Eligibility criteria included reporting of at least one of the following primary outcome measures: early allograft dysfunction (EAD), biliary complications, and graft survival. A random‐effects Bayesian NMA with a non‐informative prior was conducted. Results Thirteen RCTs were included with a total of 1888 recipients and assessed 5 interventions. IFLT had the highest probability of being the best‐ranked treatment for EAD and biliary complications, but these findings were based on a single RCT. HMP (7 RCTs) ranked higher than NMP (4 RCTs) across all primary outcomes, whereas NMP ranked higher than SCS for EAD and biliary complications. Subgroup analysis of extended criteria brain‐dead donors was consistent with overall findings. Conclusions Dynamic preservation modalities were associated with improved outcomes compared with SCS. HMP ranked higher than NMP across the primary outcomes. However, these comparisons were predominantly indirect and do not establish superiority of HMP over NMP.
ABSTRACT Background Advanced biventricular heart failure may require durable biventricular assist device (BiVAD) support when heart transplantation is not immediately feasible or patients are ineligible for heart transplantation. We aimed to compare baseline characteristics, perioperative features, and clinical outcomes between patients supported with HeartMate 3‐BiVAD (HM3‐BiVAD) and HeartWare‐BiVAD (HW‐BiVAD). Methods A systematic search was performed in October 2025 across MEDLINE, Embase, Cochrane Library, Scopus, and CINAHL. We identified studies of adult patients supported with dual HeartMate 3 LVAD and HeartWare HVAD continuous‐flow pumps in a BiVAD configuration. Study‐level data were pooled to compare patients supported with HM3‐BiVAD and those with HW‐BiVAD. Results The proportion of females was significantly lower among HM3‐BiVAD patients [HM3: 4.8% (95% CI: 1.2, 17.1) vs. HW: 22.5% (16.8, 29.4), p = 0.02], whereas patient age was comparable between groups [HM3: 47 (43, 52) years vs. HW: 48 (45, 50) years, p = 0.9]. Chronic kidney disease [HM3: 57.1% (23, 85.6) vs. HW: 10.9% (4.6, 23.6), p = 0.01] was more common among HM3‐BiVAD patients. Concomitant right ventricular assist device (RVAD) placement was the predominant approach across both groups [HM3: 66.2% (35.5, 87.4) vs. HW: 78.5% (70.1, 85), p = 0.36]. Right atrium was used more frequently as RVAD implantation site in the HM3‐BiVAD group [HM3: 96.7% (63.4, 99.8) vs. HW: 33.9% (19, 52.9), p = 0.01], whereas the right ventricle predominated in the HW‐BiVAD group [HM3: 3.2% (0.2, 36.6) vs. HW: 64.5% (45.2, 80.1), p = 0.01]. Overall survival was significantly higher among HM3‐BiVAD patients [78.1% (49.3, 92.9)] compared to HW‐BiVAD patients [48% (40.6, 55.4); p = 0.05]. The mean follow‐up was 274 (200, 349) days in patients with HM3‐BiVAD and 210 (143, 277) days in HW‐BiVAD patients ( p = 0.21). Conclusion Patients with HW‐BiVAD were characterized by a higher proportion of females and more frequent use of the RV as the RVAD implantation site, likely both due to the smaller device profile. HM3‐BiVAD patients demonstrated higher post‐implant survival despite a more severe preimplant clinical profile, suggesting a possible device‐related advantage.
ABSTRACT Introduction Renal hypoperfusion, driven by reduced mean arterial pressure or increased venous congestion, contributes to acute kidney injury in cardiogenic shock. Assessing cardiovascular support strategies for patients with cardiogenic shock requires controlled platforms such as mock circulatory loops (MCLs). However, most MCLs lack renal autoregulation or do not account for venous pressure, risking inaccurate renal flow estimation. Here, we describe how to implement a perfusion pressure‐based autoregulated renal circulation within an MCL. Methods A renal circulation was integrated into an existing biventricular MCL. Renal vascular resistance was dynamically adjusted according to a perfusion pressure‐renal flow relationship. Autoregulation performance was quantified by mean square error between measured and theoretical renal flow. Left, right, and biventricular cardiogenic shock were simulated. Extracorporeal Membrane Oxygenation (ECMO) support and fluid doses were used as clinically relevant interventions to modify the arterial and venous determinants of perfusion pressure. Results Renal autoregulation closely reproduced the target relationship, with mean square error 0.001 (L/min) 2 . Increasing ECMO flow increased perfusion pressure through higher mean arterial pressure (MAP) and lower mean right atrial pressure (MRAP) across all ventricular failure phenotypes. Conversely, fluid doses increased both MAP and MRAP, with the magnitude of MRAP elevation varying by ventricular failure phenotype and partially offsetting the increase in MAP, resulting in smaller increases in perfusion pressure. Renal flow responses reflected perfusion pressure rather than arterial pressure alone. Conclusion Renal flow‐perfusion pressure autoregulation can be accurately implemented in an MCL. Incorporating such renal autoregulation improves physiological fidelity of MCLs and evaluation of cardiovascular devices.
ABSTRACT Background Short‐duration (1–2 h) dual hypothermic oxygenated machine perfusion (DHOPE) reduces ischemia‐reperfusion injury‐related complications. Prolonged DHOPE preservation (DHOPE‐PRO) may facilitate logistics. We assessed the economic impact of DHOPE‐PRO versus conventional short‐duration DHOPE, hypothesizing that DHOPE‐PRO would not be associated with increased one‐year transplantation‐related costs. Methods This post hoc economic evaluation of the prospective DHOPE‐PRO trial (NL8740) included adult recipients of livers donated after brain death. All transplantation‐related medical expenses up to one year post‐transplant were collected. The cost of resource use was calculated using 2022 full hospital prices indexed to 2024. Time‐driven variable costing was applied to perfusion, surgery, and intensive care costs. The primary outcome was total one‐year transplantation‐related cost. Results Of 24 patients, 12 received a liver after DHOPE and 12 after DHOPE‐PRO. Median one‐year total costs were €83 583 [interquartile range (IQR) 78 400–104 158] for DHOPE and €78 582 [IQR 73123–92 855] for DHOPE‐PRO ( p = 0.347). Perfusion costs were higher with DHOPE‐PRO (€23 926 [IQR 22711–24 697] versus €17 306 [IQR 16928–17 594]; p < 0.001), while surgery costs were lower (€18 560 [IQR 17806–20 747] versus €21 303 [IQR 19535–25 418]; p = 0.033). Costs related to other medical activities did not differ between groups. Conclusion In this exploratory single‐center economic evaluation, DHOPE‐PRO enabled daytime liver transplantation without evidence of increased one‐year transplantation‐related costs compared with short‐duration DHOPE. Higher perfusion‐related costs were accompanied by lower surgery‐related costs in this cohort. These findings warrant confirmation in larger studies. Trial Registration Netherlands Trial Registry number: NL8740
