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It's All for the Children

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Scott Feitell, DO
Drexel College of Medicine
Philadelphia, PA, USA

If there is one thing I take away from this session almost immediately, it is that I made the right choice going into adult cardiology. It is readily apparent that with so little data and so few options for these poor pediatric patients, that many decisions are made on a "wing and a prayer" (and perhaps a skilled surgeon helps). The Pre-Meeting Symposium 18: Developing a Pediatric VAD Program session began with a great overview by Dr. Peter Weardon on what options are available for our pediatric patients when mechanical circulatory support is needed.

One thing was certain by Dr. Weardon's talk. These devices aren't cheap, and with little data, and such small patient pools to gather data from, it takes a lot of user experience and a lot of troubleshooting to be successful in implanting our young patients. Certainly tools like CT mapping can aid in assessing anatomical limitations and having to "cram" a VAD into a patient as Dr. Weardon put it. Assessing the possibility of recoverability in a few weeks, body size and weight are key parameters.

Dr. Holger Buchholz took the discussion one step further, by asking what next? Just because Dr. Weardon can put one of these VADs into a pediatric patient, what happens once it is in. Trying to get a pediatric patient home after VAD placement is a tremendous undertaking and requires a great deal of education and support. Dr. Buchholz reviewed the program in place in Edmonton, including the team set up, a need for 24/7 on-call physicians and coordinators to help families. Over 30 hours of training is needed for families to master all the skills necessary to triage and help the patient. Modern technology such as the Facetime App on iPhones allows instant communication regardless of distance between physician and patient. For patient's that live farther from the implant center, training must be arranged with local physicians, school nurses and local family/friends so that issues can be addressed in a timely fashion.

Dr. Jennifer Conway then focused on the types of complications that must be contended with, and the many psychosocial issues that must be addressed in this young population. To further complicate management, many treatment options that would otherwise be available to adult LVAD patients are unproven and untested in pediatric populations, such as the use of TPA for pump thrombosis. Dr. Conway further notes the long-term psychological ramifications of LVAD use in pediatric patients is simply unknown.

Aileen Lin, an LVAD nurse at Stanford offered some useful incite into these issues and use excellent case examples to further illustrate these problems. Morbid obesity presents a huge limitation to transplant due to increased complications such as infection postoperatively. She did note that LVAD placement with weight management strategies such as bariatric surgery may provide some help. She also was key to point out that the long-term psychosocial impact on these children remains largely unknown and will require careful observation in the future to ensure they have good quality of life.

The session closed with Dr. Martin Schweiger providing some unique pediatric case reports that presented a great deal of challenges. An interesting case of Kawasaki Vasculopathy and a VSD patch correction that unmasked concomitant myocarditis provided some stunning images under cine in the cath lab as well as the perils of charting into unchartered territories with ventricular support devices.

All in all, the session provided a great deal of insight into the perils and pitfalls of managing the pediatric population with advanced heart failure symptoms, but it also provided a great deal of hope that much can be done to provide these patients with a full and bright future.

Disclosure Statement: the author has no conflicts of interest to report.

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