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Pediatric Heart Transplantation Bridged With Ventricular Assist Devices
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Pediatric Heart Transplantation Bridged With Ventricular Assist Devices J.-M. Luo, N.-K. Chou, N.-H. Chi, Y.-S. Chen, H.-Y. Yu, C.-H. Wang, W.-J. Ko, C.-I. Tsao, C.-D. Sun, and S.-S. Wang ABSTRACT Heart transplantation (HTx) is indicated in children with end-stage heart failure or complex inoperable congenital defects. Because of the shortage of pediatric donor hearts, various bridge techniques have been used in pediatric patients to prolong patient survival until a suitable heart becomes available. We reviewed medical records of several pediatric patients in whom bridging with ventricular assist devices was used. All of the patients survived HTx, and are alive and well with no neurologic sequelae. They are NYHA functional class I. Thus, morbidity and mortality were acceptable in this high-risk group of pediatric patients with a ventricular assist device bridging to HTx. EART TRANSPLANTATION (HTx) is currently the treatment of choice for end-stage heart disease in children.1 Because of the long time on the waiting list, various bridge techniques have been used in pediatric recipients to prolong survival until a suitable heart becomes available. The mainstay of pediatric mechanical support has historically been extracorporeal membrane oxygenation (ECMO).2– 4 Several drawbacks are associated with ECMO including the limited time that patients can be adequately supported without life-threatening complications. Furthermore, patients generally require intubation and sedation, preventing adequate rehabilitation and mobilization.5 However, ventricular assist devices (VADs) have been used successfully in adult patients for longer support as a bridge to transplantation or destination therapy.6,7 In addition, VADs can be used for weeks or months, enabling patients to await a suitable organ. The use of VADs in the pediatric population has evolved over the last decade. Thus, we re-
H
© 2010 Published by Elsevier Inc. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 42, 913–915 (2010)
viewed the medical records for several pediatric transplant recipients in whom a VAD was used as a bridge to HTx. PATIENTS AND METHODS We performed 28 HTx procedures in 2008, including 7 in pediatric patients, 3 of whom required a VAD as a bridge to HTx. Two of the 3 patients (66.7%) required preoperative ECMO support before the change to VAD support.
Case Reports Case 1. A 9-year-old boy had dilated cardiomyopathy, mitral regurgitation, and pleural effusion. He was transferred to our From the Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei, Taiwan. Address reprint requests to Shoei-Shen Wang, MD, PhD, Department of Cardiovascular Surgery, National Taiwan University Hospital, No. 7 Chung-Shan South Road, Taipei 100, Taiwan. E-mail: [email protected] 0041-1345/–see front matter doi:10.1016/j.transproceed.2010.02.046 913
914 hospital on March 19, 2008. After admission, an echocardiogram demonstrated a dilated heart with a poor left ventricular ejection fraction (LVEF) of 20% to 30%, and moderate mitral and tricuspid valve regurgitation. Because of low-output cardiac symptoms, a left VAD was implanted on April 12 and the patient was placed on the transplantation waiting list. Support was with a Thoratec VAD (Thoratec Corp, Pleasanton, California) with inlet and outlet cannulas. During VAD support, 1 episode of right common femoral artery thrombus formation occurred at the insertion site of the VAD cannula. After thrombectomy, there was a fair degree of arterial flow. Empirical antibiotic therapy was administered continuously because of spiking fever and poor condition of the Thoratec femoral wound. The patient received VAD support for 54 days before undergoing orthotopic HTx on June 4. Extubation was performed on postoperative day 1. Rabbit antithymocyte globulin and intravenous steroids were administered on postoperative day 1. Because of the high risk of VAD cannula tract infection, the rabbit antithymocyte globulin therapy was stopped, and tacrolimus (FK506), mycophenolate mofetil (CellCept; Genentech Inc, South San Francisco, California), and prednisolone therapy was initiated on June 5. The patient was transferred to a general ward for further monitoring and management on June 11. Endomyocardial biopsy was performed several times, and the specimens exhibited no evidence of rejection. Subsequent serial echocardiograms demonstrated good left ventricular contractility. Leukocytosis improved gradually, and antibiotic therapy was discontinued, with resolution of infection. Because of his stable condition, the patient was discharged. Regular outpatient follow-up demonstrated no evidence of rejection or decline in heart function. Case 2. An 8-year-old boy had been healthy before April 2007, when he experienced a common cold and vomiting with abdominal pain. An echocardiogram demonstrated a low LVEF (about 17%) associated with dilated cardiomyopathy, suggestive of acute exacerbation or subacute myocarditis. After treatment, the patient was discharged. However, in 2008, he experienced 2 episodes of dilated cardiomyopathy with heart decompensation. A VAD was implanted on September 28, 2008, using Medos vascular cannulas for inlet and outlet ports. An emergent head computed tomography (CT) scan showed a hypodense lesion in the right frontal base and left cerebellar hemisphere, most likely due to an embolic stroke in the right anterior cerebral artery and left anterior cerebellar artery. Cardiac sonography demonstrated an obvious thrombus in the left atrium and left ventricle. However, there was no focal neurologic deficit or deterioration of consciousness. Heparin infusion was continued, and the circuit of the left VAD was changed. The patient received VAD support for 6 days before orthotopic HTx on October 3. The donor was a 32-year-old woman who had committed suicide via carbon monoxide intoxication; total ischemia time was 90 minutes. Extubation was performed on postoperative day 1. Antibiotic therapy was continued until the infection was well under control. The patient was transferred to a general ward on October 8, where antibiotic therapy was continued and a rehabilitation program was initiated. Subsequent echocardiograms shows good heart function, and antibiotic therapy was discontinued after 14 days. Because of his stable condition, the patient was discharged, with regular outpatient follow-up. During this period, an arrhythmia was noted, and the patient was readmitted on July 29, 2009. To treat atrial flutter, we prescribed an antiplatelet agent, diuretics, digoxin, and amidarone. The patient’s condition improved, and CT scans demonstrated relatively preserved left ventricular contractility. The patient was discharged in stable condition. He was readmitted on August 12. On the following day, he underwent
LUO, CHOU, CHI ET AL radiofrequency catheter ablation because of ectopic atrial tachycardia in the right inferior area near the suture line and isthmusdependent atrial flutter. After catheterization, there was no chest tightness, palpitations, or cold sweats. Subsequent electrocardiograms demonstrated no significant abnormalities, and the patient was discharged, with benign follow-up. Case 3. A 14-year-old youth had chronic heart failure, dilated cardiac myopathy, and mitral valve regurgitation. Initially, inotropic agents and ECMO support with sedation were administered. A left VAD was implanted on December 13, 2008, using Medos vascular cannulas for inlet and outlet ports because of the small size of the heart and aorta. The VAD included a levotronix pump. The ECMO was discontinued on December 14. Because of disorientation and visual handicap during VAD support, a brain CT scan was obtained, which demonstrated multiple infarctions. After discontinuing sedation, consciousness returned, with transient right-sided hemianopia and mild confusion. The patient received VAD support for 12 days before undergoing orthotopic HTx on December 24. Postoperatively, the patient initially received ECMO and inotropic agents including dopamine, milrinone, and epinephrine. Rabbit antithymocyte globulin was prescribed for immunosuppression, which was effective, as evidenced by a low T-cell count. Fever developed on December 27. A complete workup for sepsis failed to reveal an obvious focus. Subsequent echocardiograms demonstrated poor LVEF initially, which was much improved (53%) on December 29. Thus, ECMO was discontinued on the following day, and extubation was performed on January 1, 2009. The right-sided weakness improved gradually. An endomyocardial biopsy specimen obtained on January 5 showed no rejection. Cyclosporine dosage was adjusted according to drug concentration. Subsequent echocardiograms demonstrated good heart function, and antibiotic therapy was discontinued after 14 days. Because of his stable condition, the patient was discharged, with regular outpatient follow-up. No neurologic deficits were noted during follow-up.
RESULTS
All 3 patients were successfully bridged to HTx after VAD support for 54, 12, and 6 days, respectively (mean, 24 days). In patient 1, an episode of right common femoral artery thrombus at the VAD cannula insertion site required thrombectomy. Although there was fair arterial flow, the pocket of the VAD cannula healed poorly because of a wound infection. With antibiotic therapy, the wound healed gradually. No wound infection was noted in the other 2 patients. Patients 2 and 3 developed mild cerebral embolization. In patient 2, the infarction initially was manifested as an episode of generalized myoclonic seizures, which subsided after intravenous injection of lorazepam. In addition, phenytoin load was administered intravenously. Emergent head CT demonstrated a hypodense lesion in the right frontal base and left cerebellar hemisphere, probably due to an embolic stroke. Cardiac ultrasound demonstrated an obvious thrombus in the left atrium and left ventricle. No focal neurologic deficits or deterioration in consciousness was noted. Therefore, heparin infusion was continued, and the left VAD circuit was changed. In patient 3, the infarction was manifested initially with disorientation and visual handicap. Emergent brain CT demonstrated a low-density change at the left parieto-occipital, left frontoparietal, left temporal,
PEDIATRIC HTx WITH VENTRICULAR ASSIST DEVICES
and right parieto-occipital lobes, and the right frontal operculum, presumably reflecting multiple infarctions. Hydration was continued, and anticoagulant agents were administered. No focal neurologic deficit or deterioration in consciousness was noted during follow-up. In patient 2, atrial flutter, noted during outpatient followup, required admission to the hospital for radiofrequency catheter ablation. Cardiac catheter examination revealed ectopic atrial tachycardia in the right inferior area near the suture line and isthmus-dependent atrial flutter. Thereafter, electrocardiograms demonstrated no significant abnormalities. All 3 patients were successfully bridged to HTx after VAD support, and have survived HTx for 14, 10, and 8 months, respectively. To date, all are alive and well, with no neurologic sequelae, and in New York Heart Association (NYHA) functional class I. DISCUSSION
Heart transplantation is currently the treatment of choice for pediatric heart disease.1 Because of the long waiting time for an allograft, various bridge techniques have been used to prolong patient survival until a suitable heart becomes available. Patients who are candidates for VAD include those who have undergone cardiotomy, have lowoutput syndrome, experience acute heart failure, or exhibit clinical deterioration despite maximum pharmacologic support. Organ shortage is an important cause of death in patients on the waiting list. Other studies have shown that an ideal mechanical bridge fulfills 3 objectives: it can be partially or fully implanted, enabling circulatory support in patients with irreversible cardiac failure; it improves hemodynamic status and reverses end-organ dysfunction; and it enables physical rehabilitation to improve the patient’s overall condition.8 Despite use of VAD technology developed for adults, our findings demonstrate that VADs may be used as bridge to transplantation in children, with the expectation of a successful outcome in most patients. Our pediatric patients with intractable heart failure were successfully bridged with
915
VAD to HTx. Because of the limited array of pediatric cannulas, we used a hybrid combination of Medos and a biopump or a levotronix pump. Our 3 patients were successfully bridged to HTx after VAD support for 54, 12, and 6 days, respectively, and have survived HTx for 14, 10, and 8 months. To date, all are alive and well, with no neurologic sequelae, in NYHA functional class I. In conclusion, VAD support may be one method to bridge to HTx in pediatric patients with end-stage heart disease. This technique may decrease morbidity and mortality during the waiting period for a suitable heart. After HTx, patients can be expected to survive without sequelae. REFERENCES 1. Canter CE, Shaddy RE, Bernstein D, et al: Indications for heart transplantation in pediatric heart disease: a scientific statement from the American Heart Council on Cardiovascular Disease in the Young; the Councils on Clinical Cardiology, Cardiovascular Nursing, and Cardiovascular Surgery and Anesthesia; and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 115:658, 2007 2. del Nido PJ, Armitage JM, Ficker FJ, et al: Extracorporeal membrane oxygenation support as a bridge to pediatric heart transplantation. Circulation 90(5 pt 2):1166, 1994 3. Gajarski RJ, Mosca RS, Ohye RG, et al: Use of extracorporeal life support as a bridge to pediatric cardiac transplantation. J Heart Lung Transplant 22:28, 2003 4. Fiser WP, Yetman AT, Gunselman RJ, et al: Pediatric arteriovenous extracorporeal membrane oxygenation (ECMO) as a bridge to cardiac transplantation. J Heart Lung Transplant 22:770, 2003 5. Bastardi HJ, Naftel DC, Webber SA, et al: Ventricular assist devices as a bridge to heart transplantation in children. J Cardiovasc Nur 23:25, 2008 6. Rose EA, Gelijns AC, Moskowitz AJ, et al; Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) Study Group: Long-term mechanical left ventricular assistance for endstage heart failure. N Engl J Med 345:1435, 2001 7. Long JW, Kfoury AG, Slaughter MS, et al: Long-term destination therapy with the HeartMate XVE left ventricular assist device: improved outcomes since the REMATCH study. Congest Heart Fail 11:133, 2005 8. Herrington CS, Tsirka AE: Pediatric cardiac transplantation. Semin Thorac Cardiovasc Surg 16:404, 2004
Pediatric Heart Transplantation Bridged With Ventricular Assist Devices J.-M. Luo, N.-K. Chou, N.-H. Chi, Y.-S. Chen, H.-Y. Yu, C.-H. Wang, W.-J. Ko, C.-I. Tsao, C.-D. Sun, and S.-S. Wang ABSTRACT Heart transplantation (HTx) is indicated in children with end-stage heart failure or complex inoperable congenital defects. Because of the shortage of pediatric donor hearts, various bridge techniques have been used in pediatric patients to prolong patient survival until a suitable heart becomes available. We reviewed medical records of several pediatric patients in whom bridging with ventricular assist devices was used. All of the patients survived HTx, and are alive and well with no neurologic sequelae. They are NYHA functional class I. Thus, morbidity and mortality were acceptable in this high-risk group of pediatric patients with a ventricular assist device bridging to HTx. EART TRANSPLANTATION (HTx) is currently the treatment of choice for end-stage heart disease in children.1 Because of the long time on the waiting list, various bridge techniques have been used in pediatric recipients to prolong survival until a suitable heart becomes available. The mainstay of pediatric mechanical support has historically been extracorporeal membrane oxygenation (ECMO).2– 4 Several drawbacks are associated with ECMO including the limited time that patients can be adequately supported without life-threatening complications. Furthermore, patients generally require intubation and sedation, preventing adequate rehabilitation and mobilization.5 However, ventricular assist devices (VADs) have been used successfully in adult patients for longer support as a bridge to transplantation or destination therapy.6,7 In addition, VADs can be used for weeks or months, enabling patients to await a suitable organ. The use of VADs in the pediatric population has evolved over the last decade. Thus, we re-
H
© 2010 Published by Elsevier Inc. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 42, 913–915 (2010)
viewed the medical records for several pediatric transplant recipients in whom a VAD was used as a bridge to HTx. PATIENTS AND METHODS We performed 28 HTx procedures in 2008, including 7 in pediatric patients, 3 of whom required a VAD as a bridge to HTx. Two of the 3 patients (66.7%) required preoperative ECMO support before the change to VAD support.
Case Reports Case 1. A 9-year-old boy had dilated cardiomyopathy, mitral regurgitation, and pleural effusion. He was transferred to our From the Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei, Taiwan. Address reprint requests to Shoei-Shen Wang, MD, PhD, Department of Cardiovascular Surgery, National Taiwan University Hospital, No. 7 Chung-Shan South Road, Taipei 100, Taiwan. E-mail: [email protected] 0041-1345/–see front matter doi:10.1016/j.transproceed.2010.02.046 913
914 hospital on March 19, 2008. After admission, an echocardiogram demonstrated a dilated heart with a poor left ventricular ejection fraction (LVEF) of 20% to 30%, and moderate mitral and tricuspid valve regurgitation. Because of low-output cardiac symptoms, a left VAD was implanted on April 12 and the patient was placed on the transplantation waiting list. Support was with a Thoratec VAD (Thoratec Corp, Pleasanton, California) with inlet and outlet cannulas. During VAD support, 1 episode of right common femoral artery thrombus formation occurred at the insertion site of the VAD cannula. After thrombectomy, there was a fair degree of arterial flow. Empirical antibiotic therapy was administered continuously because of spiking fever and poor condition of the Thoratec femoral wound. The patient received VAD support for 54 days before undergoing orthotopic HTx on June 4. Extubation was performed on postoperative day 1. Rabbit antithymocyte globulin and intravenous steroids were administered on postoperative day 1. Because of the high risk of VAD cannula tract infection, the rabbit antithymocyte globulin therapy was stopped, and tacrolimus (FK506), mycophenolate mofetil (CellCept; Genentech Inc, South San Francisco, California), and prednisolone therapy was initiated on June 5. The patient was transferred to a general ward for further monitoring and management on June 11. Endomyocardial biopsy was performed several times, and the specimens exhibited no evidence of rejection. Subsequent serial echocardiograms demonstrated good left ventricular contractility. Leukocytosis improved gradually, and antibiotic therapy was discontinued, with resolution of infection. Because of his stable condition, the patient was discharged. Regular outpatient follow-up demonstrated no evidence of rejection or decline in heart function. Case 2. An 8-year-old boy had been healthy before April 2007, when he experienced a common cold and vomiting with abdominal pain. An echocardiogram demonstrated a low LVEF (about 17%) associated with dilated cardiomyopathy, suggestive of acute exacerbation or subacute myocarditis. After treatment, the patient was discharged. However, in 2008, he experienced 2 episodes of dilated cardiomyopathy with heart decompensation. A VAD was implanted on September 28, 2008, using Medos vascular cannulas for inlet and outlet ports. An emergent head computed tomography (CT) scan showed a hypodense lesion in the right frontal base and left cerebellar hemisphere, most likely due to an embolic stroke in the right anterior cerebral artery and left anterior cerebellar artery. Cardiac sonography demonstrated an obvious thrombus in the left atrium and left ventricle. However, there was no focal neurologic deficit or deterioration of consciousness. Heparin infusion was continued, and the circuit of the left VAD was changed. The patient received VAD support for 6 days before orthotopic HTx on October 3. The donor was a 32-year-old woman who had committed suicide via carbon monoxide intoxication; total ischemia time was 90 minutes. Extubation was performed on postoperative day 1. Antibiotic therapy was continued until the infection was well under control. The patient was transferred to a general ward on October 8, where antibiotic therapy was continued and a rehabilitation program was initiated. Subsequent echocardiograms shows good heart function, and antibiotic therapy was discontinued after 14 days. Because of his stable condition, the patient was discharged, with regular outpatient follow-up. During this period, an arrhythmia was noted, and the patient was readmitted on July 29, 2009. To treat atrial flutter, we prescribed an antiplatelet agent, diuretics, digoxin, and amidarone. The patient’s condition improved, and CT scans demonstrated relatively preserved left ventricular contractility. The patient was discharged in stable condition. He was readmitted on August 12. On the following day, he underwent
LUO, CHOU, CHI ET AL radiofrequency catheter ablation because of ectopic atrial tachycardia in the right inferior area near the suture line and isthmusdependent atrial flutter. After catheterization, there was no chest tightness, palpitations, or cold sweats. Subsequent electrocardiograms demonstrated no significant abnormalities, and the patient was discharged, with benign follow-up. Case 3. A 14-year-old youth had chronic heart failure, dilated cardiac myopathy, and mitral valve regurgitation. Initially, inotropic agents and ECMO support with sedation were administered. A left VAD was implanted on December 13, 2008, using Medos vascular cannulas for inlet and outlet ports because of the small size of the heart and aorta. The VAD included a levotronix pump. The ECMO was discontinued on December 14. Because of disorientation and visual handicap during VAD support, a brain CT scan was obtained, which demonstrated multiple infarctions. After discontinuing sedation, consciousness returned, with transient right-sided hemianopia and mild confusion. The patient received VAD support for 12 days before undergoing orthotopic HTx on December 24. Postoperatively, the patient initially received ECMO and inotropic agents including dopamine, milrinone, and epinephrine. Rabbit antithymocyte globulin was prescribed for immunosuppression, which was effective, as evidenced by a low T-cell count. Fever developed on December 27. A complete workup for sepsis failed to reveal an obvious focus. Subsequent echocardiograms demonstrated poor LVEF initially, which was much improved (53%) on December 29. Thus, ECMO was discontinued on the following day, and extubation was performed on January 1, 2009. The right-sided weakness improved gradually. An endomyocardial biopsy specimen obtained on January 5 showed no rejection. Cyclosporine dosage was adjusted according to drug concentration. Subsequent echocardiograms demonstrated good heart function, and antibiotic therapy was discontinued after 14 days. Because of his stable condition, the patient was discharged, with regular outpatient follow-up. No neurologic deficits were noted during follow-up.
RESULTS
All 3 patients were successfully bridged to HTx after VAD support for 54, 12, and 6 days, respectively (mean, 24 days). In patient 1, an episode of right common femoral artery thrombus at the VAD cannula insertion site required thrombectomy. Although there was fair arterial flow, the pocket of the VAD cannula healed poorly because of a wound infection. With antibiotic therapy, the wound healed gradually. No wound infection was noted in the other 2 patients. Patients 2 and 3 developed mild cerebral embolization. In patient 2, the infarction initially was manifested as an episode of generalized myoclonic seizures, which subsided after intravenous injection of lorazepam. In addition, phenytoin load was administered intravenously. Emergent head CT demonstrated a hypodense lesion in the right frontal base and left cerebellar hemisphere, probably due to an embolic stroke. Cardiac ultrasound demonstrated an obvious thrombus in the left atrium and left ventricle. No focal neurologic deficits or deterioration in consciousness was noted. Therefore, heparin infusion was continued, and the left VAD circuit was changed. In patient 3, the infarction was manifested initially with disorientation and visual handicap. Emergent brain CT demonstrated a low-density change at the left parieto-occipital, left frontoparietal, left temporal,
PEDIATRIC HTx WITH VENTRICULAR ASSIST DEVICES
and right parieto-occipital lobes, and the right frontal operculum, presumably reflecting multiple infarctions. Hydration was continued, and anticoagulant agents were administered. No focal neurologic deficit or deterioration in consciousness was noted during follow-up. In patient 2, atrial flutter, noted during outpatient followup, required admission to the hospital for radiofrequency catheter ablation. Cardiac catheter examination revealed ectopic atrial tachycardia in the right inferior area near the suture line and isthmus-dependent atrial flutter. Thereafter, electrocardiograms demonstrated no significant abnormalities. All 3 patients were successfully bridged to HTx after VAD support, and have survived HTx for 14, 10, and 8 months, respectively. To date, all are alive and well, with no neurologic sequelae, and in New York Heart Association (NYHA) functional class I. DISCUSSION
Heart transplantation is currently the treatment of choice for pediatric heart disease.1 Because of the long waiting time for an allograft, various bridge techniques have been used to prolong patient survival until a suitable heart becomes available. Patients who are candidates for VAD include those who have undergone cardiotomy, have lowoutput syndrome, experience acute heart failure, or exhibit clinical deterioration despite maximum pharmacologic support. Organ shortage is an important cause of death in patients on the waiting list. Other studies have shown that an ideal mechanical bridge fulfills 3 objectives: it can be partially or fully implanted, enabling circulatory support in patients with irreversible cardiac failure; it improves hemodynamic status and reverses end-organ dysfunction; and it enables physical rehabilitation to improve the patient’s overall condition.8 Despite use of VAD technology developed for adults, our findings demonstrate that VADs may be used as bridge to transplantation in children, with the expectation of a successful outcome in most patients. Our pediatric patients with intractable heart failure were successfully bridged with
915
VAD to HTx. Because of the limited array of pediatric cannulas, we used a hybrid combination of Medos and a biopump or a levotronix pump. Our 3 patients were successfully bridged to HTx after VAD support for 54, 12, and 6 days, respectively, and have survived HTx for 14, 10, and 8 months. To date, all are alive and well, with no neurologic sequelae, in NYHA functional class I. In conclusion, VAD support may be one method to bridge to HTx in pediatric patients with end-stage heart disease. This technique may decrease morbidity and mortality during the waiting period for a suitable heart. After HTx, patients can be expected to survive without sequelae. REFERENCES 1. Canter CE, Shaddy RE, Bernstein D, et al: Indications for heart transplantation in pediatric heart disease: a scientific statement from the American Heart Council on Cardiovascular Disease in the Young; the Councils on Clinical Cardiology, Cardiovascular Nursing, and Cardiovascular Surgery and Anesthesia; and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 115:658, 2007 2. del Nido PJ, Armitage JM, Ficker FJ, et al: Extracorporeal membrane oxygenation support as a bridge to pediatric heart transplantation. Circulation 90(5 pt 2):1166, 1994 3. Gajarski RJ, Mosca RS, Ohye RG, et al: Use of extracorporeal life support as a bridge to pediatric cardiac transplantation. J Heart Lung Transplant 22:28, 2003 4. Fiser WP, Yetman AT, Gunselman RJ, et al: Pediatric arteriovenous extracorporeal membrane oxygenation (ECMO) as a bridge to cardiac transplantation. J Heart Lung Transplant 22:770, 2003 5. Bastardi HJ, Naftel DC, Webber SA, et al: Ventricular assist devices as a bridge to heart transplantation in children. J Cardiovasc Nur 23:25, 2008 6. Rose EA, Gelijns AC, Moskowitz AJ, et al; Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) Study Group: Long-term mechanical left ventricular assistance for endstage heart failure. N Engl J Med 345:1435, 2001 7. Long JW, Kfoury AG, Slaughter MS, et al: Long-term destination therapy with the HeartMate XVE left ventricular assist device: improved outcomes since the REMATCH study. Congest Heart Fail 11:133, 2005 8. Herrington CS, Tsirka AE: Pediatric cardiac transplantation. Semin Thorac Cardiovasc Surg 16:404, 2004