ASAIO journal : a peer-reviewed journal of the American Society for Artificial Internal Organs
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The use of venoarterial extracorporal membrane oxygenation and ventricular assist-devices in children with end stage heart failure is well established. The use of a bridge-to-bridge strategy leads to excellent survival rates in pediatric patients. We present an adolescent, who acquired acute respiratory failure, due to possible transfusion related lung injury, and who was successfully treated with venovenous extracorporal membrane oxygenation while on ventricular assist-device support.
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Mechanical circulatory support is gaining increased recognition as a viable treatment option for pediatric patients who suffer from congenital or acquired heart disease. Historically, the treatment options have been very limited for pediatric patients, but recent technological advances, combined with new research into circulatory support devices, are seeking alternative therapeutics options for infants and children. ⋯ The National Heart, Lung, and Blood Institute pediatric circulatory support program is discussed, in addition to the use of adult devices in pediatric applications, the Berlin Heart Excor, and several other blood pumps in development for bridge-to-transplant and bridge-to-recovery support. These devices have the potential to generate a paradigm shift in the treatment of the pediatric patients with heart failure--a shift is likely already be underway.
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For children requiring mechanical circulatory support as a bridge to cardiac transplantation in North America, options previously were limited to extracorporeal membrane oxygenation (ECMO) or centrifugal pump ventricular assist, both of which were suitable for only very short term application and were associated with significant complications and limitations. The Berlin Heart EXCOR ventricular assist device (VAD) was recently introduced into practice in North America to address this deficiency. We report a preliminary single center experience with the EXCOR in 17 children, 13 who received only a left-sided pump and four who required biventricular support. ⋯ Complications included stroke in seven patients, two of which were ultimately fatal. Five patients required re-operations for bleeding or evacuation of hematoma. Despite a disappointing rate of neurologic morbidity, our preliminary experience with the EXCOR has been very encouraging.
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We describe a process by which we sought to determine how the addition of intraoperative neurophysiologic monitoring (IONM) impacted the management of cardiopulmonary bypass (CPB) during pediatric cardiac surgery. While maintaining a consistent team of surgeons, anesthesiologists, nurses, and perfusionists, a multi-modal, IONM program was established consisting of Near Infrared Spectroscopy, Transcranial Doppler, and eight channel electroencephalography. ⋯ This comparative analysis of CPB management revealed a significant increase in the use of donor blood added to the CPB circuit prime as well as in the maintenance of a higher hematocrit during the bypass period after the implementation of IONM. These changes in the management of pediatric CPB correlated with recommendations of previous studies that examined postoperative neurophysiologic outcomes, suggesting that these changes were not only consistent with best practices, but that the presence of IONM data facilitated a transition to evidence-based practice.
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This study investigated delivery of gaseous microemboli (GME) with vacuum-assisted venous drainage (VAVD) at various flow rates and perfusion modes in a simulated neonatal cardiopulmonary bypass (CPB) model. Four transducers (postpump, postoxygenator, postfilter, and venous line) of the emboli detection and classification (EDAC) quantifier were inserted into the CPB circuit to detect and classify GME. Four negative pressures (0, -15, -30, and -45 mm Hg), 3 flow rates (750, 1,000, and 1,250 ml/min), and 2 perfusion modes (pulsatile and nonpulsatile) were tested. ⋯ Compared with nonpulsatile flow, pulsatile flow transferred more GME at the postpump site at all 3 flow rates. Our results suggest that VAVD with higher negative pressures, increased flow rates, and pulsatile flow could deliver more GME at the postpump site when a fixed volume air is introduced into the venous line. The Emboli Detection and Classification Quantifier is a sensitive tool for the detection and classification of GME as small as 10 microns in this simulated neonatal model.