Pediatric VAD Growth in the US: What Factors May Be Driving Growth Jumps?

PurposeAs the use of pediatric ventricular assist device (VAD) support has grown in the US, the rate of growth has not been linear. Instead, growth has occurred in spurts. We sought to analyze growth spurts in pediatric VAD use to determine what factors may be influencing increases in VAD utilization in the US.MethodsOPTN data were used to identify all children ≤18 years listed for heart transplant between 2009 and 2019 including the proportion supported with a VAD at some point during the waiting period. VAD growth spurts were identified based on direct inspection of the annual implant volume trends. Factors independently associated with VAD growth spurts were identified using multivariable regression techniques.ResultsAmong 6,940 children who met the inclusion criteria, 769 received a VAD. Annual VAD implant growth is depicted in the Figure. Two distinct periods of rapid growth were identified, the first between 2011 and 2012, where annual usage at listing jumped 75% and the second between 2016 and 2017, where annual usage at listing increased by 36% and was sustained. Regression analyses suggest that the 2011-12 jump was driven by increased implants among infants with the Berlin Heart while the 2016-2017 jump was observed in older children, especially ages 4-6 years, and associated with several factors including growth in use of the PediMag/CentriMag system, Heartmate III, introduction of bivalirudin anticoagulation, and UNOS revisions favoring VAD over milrinone to achieve 1A status in cardiomyopathy patients. Minimal change appears related to increase of VAD implants in children with congenital heart disease.ConclusionOver the past 10 years, pediatric VAD growth has been non-linear, accelerating more rapidly at specific time periods. The 2012 jump appears driven by Berlin Heart approval and use in infants, whereas the jump beyond 2016 appears related to a variety of factors including expansion of pump options, anticoagulation strategies and potentially the 2016 UNOS allocation revisions. As the use of pediatric ventricular assist device (VAD) support has grown in the US, the rate of growth has not been linear. Instead, growth has occurred in spurts. We sought to analyze growth spurts in pediatric VAD use to determine what factors may be influencing increases in VAD utilization in the US. OPTN data were used to identify all children ≤18 years listed for heart transplant between 2009 and 2019 including the proportion supported with a VAD at some point during the waiting period. VAD growth spurts were identified based on direct inspection of the annual implant volume trends. Factors independently associated with VAD growth spurts were identified using multivariable regression techniques. Among 6,940 children who met the inclusion criteria, 769 received a VAD. Annual VAD implant growth is depicted in the Figure. Two distinct periods of rapid growth were identified, the first between 2011 and 2012, where annual usage at listing jumped 75% and the second between 2016 and 2017, where annual usage at listing increased by 36% and was sustained. Regression analyses suggest that the 2011-12 jump was driven by increased implants among infants with the Berlin Heart while the 2016-2017 jump was observed in older children, especially ages 4-6 years, and associated with several factors including growth in use of the PediMag/CentriMag system, Heartmate III, introduction of bivalirudin anticoagulation, and UNOS revisions favoring VAD over milrinone to achieve 1A status in cardiomyopathy patients. Minimal change appears related to increase of VAD implants in children with congenital heart disease. Over the past 10 years, pediatric VAD growth has been non-linear, accelerating more rapidly at specific time periods. The 2012 jump appears driven by Berlin Heart approval and use in infants, whereas the jump beyond 2016 appears related to a variety of factors including expansion of pump options, anticoagulation strategies and potentially the 2016 UNOS allocation revisions.