USE OF MULTISYSTEM MONITORING AND MULTIDRUG THERAPY IN PEDIATRIC PATIENTS IMPLANTED WITH VENTRICULAR ASSIST DEVICES:

We have previously reported on the use of multi-system monitoring (MSM) coupled with multi-drug therapy (MDT) in adult patients implanted with the CardioWest total artificial heart. Use of MSM plus MDT results in a low incidence of CVA's in this patient population. The purpose of this study is to report the use of MSM plus MDT in pediatric patients implanted with ventricular assist devices (VADs). Between July 1998 and July 2000 four patients (3 males, 1 female) with a mean age of 10 ± 3.5 years (range: 7 to 13 years old) underwent implantation with Thoratec LVAD (1 male), Thoratec BiVADS (1 male and 1 female) or Berlin BiVADs (1 male). Indications for LVADs were viral cardiomyopathy (2 patients), idiopathic dilated cardiomyopathy (1 patient) and restrictive cardiomyopathy (1 patient). MSM consisting of thrombelastography (TEG), complete blood count (CBC), platelet count, platelet aggregation studies (CTAG), prothrombin time (PT), international normalized ratio (INR), partial thromboplastin time (PTT), bleeding time (BT), renal and liver function studies, was used to individualize and monitor MDT, which consisted of unfractionated heparin, aspirin, dipyridamole, pentoxifylline and warfarin. Implant time averaged 40 ± 12.1 days (range: 23 to 50 days). All patients were successfully bridged to heart transplantation and have remained alive a total of 4 years (range: 2 months to 2.2 years) post-transplant. One of the patients experienced a right middle cerebral CVA while implanted with a Thoratec LVAD 14 days post-implant. At this time the patient was hypercoaguable by TEG, the INR had abruptly fallen from 2.7 to 1.8 and the BT was normal (8 minutes). The event did not preclude transplantation and the patient has exhibited a near-full recovery with only mild residual left-hand weakness. In conclusion, use of MSM plus MDT facilitates a high success rate of bridge to heart transplantation and post-transplant survival in pediatric patients implanted with VADs.