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Cerebral Strokes in Pediatrics on Intra-Corporeal LVADs

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Martin Schweiger, MD, PD
University Children's Hospital Zurich
Zurich, Switzerland

There has been a rapid evolution of using adult designed continuous flow VADS (cf-VADs) to support pediatrics even in children with congenital heart disease. This comes with the need for care providers specialized in this field to determine optimal patient and device selection, and to improve outcomes and decrease complication rates for new innovative strategies. The Berlin Heart EXCOR® is and has been the mainstay of long term VAD support for children of all ages but its limitations, especially the risk of thromboembolic events, are well known. Data from adult experience have shown a significant decrease in neurologic dysfunction with cf-VADs compared with pulsatile VADs in adults [1].

There are very few data on outcome especially on cerebral strokes in children supported with adulted sized LVADs. One may speculate that in children where flow rates in the VAD might be lower compared to adults, pump thrombosis and thrombo-embolic events might occur more often. The US-only Paediatric Interagency Registry for Mechanical Circulatory Support (PediMACS) database revealed cerebrovascular stroke or hemorrhage in 26%, but without stratification to body weight or BSA [2].

We sought to investigate ischemic and hemorrhagic strokes in children supported with intra-corporeal cf-LVADs depending on BSA using the largest European VAD database (European Registry for Patients with Mechanical Circulatory Support (EUROMACS)).

We identified 51 pediatric patients on cf-LVAD listed in the database. The patients were stratified by body surface area (BSA) (Group 1 < 1.2 m²,Group 2: ≥ 1.2 m²). Except age/weight and size, there was no significant difference between groups.

Except 24 patients who did not receive anticoagulation prior to LVAD placement, all others were on anticoagulation (Heparin or antiplatelet treatment or oral anticoagulation). One of the patients died due to cerebral stroke. After LVAD implantation, all the patients either received heparin or an alternative (n: 2). Only 38% received additional antiplatelet therapy including aspirin, clopidogrel, or dipyridamole.

Overall, four cerebral stroke events were observed in the older age group without reaching significance (p = 0.26). Cerebral strokes occurred between 19 and 524 days on support (mean = 244 days). All but one patient died due to this event; one patient underwent HTx.

Taken together, the incidence of cerebral strokes in this paediatric cohort of intra-corporeal VAD patients was low with 0.1 per patient year but when occurred, the event led to death in three-fourths of the patients, thus being the most frequent cause of death (37%) among the whole study population.

Acknowledgements: EUROMACS is an official committee of the European Association for Cardiothoracic Surgery (EACTS). EUROMACS also contributes data to the International Society for Heart and Lung Transplantation Registry for Mechanically Assisted Circulatory Support (IMACS). The study was granted by the Executive and Extended Board of Directors of EUROMACS (Apl.2015). Involved authors of the paper are: Oliver Miera MD.², Theo M.M.H. de By MBA.³, Michael Hübler MD. Prof.¹, Felix Berger MD. Prof.², Mustafa Özbaran MD, Prof.4;, Antonio Loforte MD.5; Burkhardt Seifert PhD., Prof.6;, Gaetano Gargiulo MD.,PhD, Prof.5, Jan Gummert MD Prof. 7;, Paul Mohacsi MD. Prof.8; on behalf of the EUROMACS members

¹ Zurich Children's Hospital, Department of Congenital Paediatric Surgery, Switzerland; ² Dpt. of Congenital Heart Disease / Paediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany; ³ Euromacs e.V. c/o Deutsches Herzzentrum Berlin, Berlin, Germany; 4; Ege Üniversitesi Tip Fakültesi; 5 Dipartimento di Chirurgia Cardio-Toraco-Vascolare e Trapianti, Policlinico S. Orsola-Malpighi, Universit√† di Bologna; 6; Department of Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland; 7; Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Universit√§tsklinik der Ruhr-Universit√§t Bochum; 8; Department of Cardiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, Switzerland

Disclosure Statement: The author has no conflicts of interest to disclose.


  1. Kirklin, J.K., et al., Fifth INTERMACS annual report: risk factor analysis from more than 6,000 mechanical circulatory support patients. J Heart Lung Transplant, 2013. 32(2): p. 141-56.
  2. Rossano, J.W., et al., Outcomes of pediatric patients supported with continuous-flow ventricular assist devices: A report from the Pediatric Interagency Registry for Mechanical Circulatory Support (PediMACS). J Heart Lung Transplant, 2016. 35(5): p. 585-90.

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