ABSTRACT
Despite improvements in operative techniques, management of cardiopulmonary bypass, and myocardial protection, myocardial dysfunction is common after complex pediatric cardiac procedures. The impaired myocardium is characterized by decreased contractile force, abnormal diastolic relaxation, and a decreasing responsiveness to inotropic stimulation (1). A common feature of heart failure is that the disease either primarily involves or eventually produces excessive hemodynamic demands on the left ventricle. Thus, there is currently a great interest in and cumulative experience with ventricular assist devices (VAD) for circulatory support. The last decade has seen a plethora of new VAD systems placed into clinical use, many being suitable for patients down to the 20 kg range. However, the experience with VAD support of smaller children «20 kg) remains limited to date. This is partly due to technical considerations and the fact that low flow rates may create a diathesis for thromboembolic complications when adult-sized systems are applied in the pediatric population (2). Moreover, there is also a longstanding perception that children with complex congenital heart disease will be unsuitable for univentricular support without an oxygenator. Many cardiac teams feel that extracorporeal membrane oxygenation (ECMO) is the best alternative, since implantable ventricular assist devices for small children are generally unavailable (3). Our own experience does not completely support this concept
(4-7). This chapter deals with our indications, technique, and outcome for shortterm circulatory support in children, primarily employing a centrifugal pump VAD (4-9). We address the following issues:
1. Design characteristics of the centrifugal pump VAD circuit. 2. Indications and contraindications for support. 3. Intraoperative decision making for suitability for VAD support. 4. Cannulation and institution of VAD support. 5. Care of the patient and device during support. 6. Weaning patients from the device. 7. Outcome analysis. 8. The role of centrifugal pump VAD in relation to paracorporeal pulsatile
devices and ECMO.
