Could Timelier Referrals for VADs Improve Outcomes in Children With CHD?

When undergoing ventricular assist device (VAD) implantation, children with congenital heart disease (CHD) are more likely to experience adverse outcomes than those without CHD, according to findings from a new Advanced Cardiac Therapies Improving Outcomes Network (ACTION) study led by the section head of Pediatric Heart Function and Transplant, Shahnawaz Amdani, MD. The study, published in the Journal of the American College of Cardiology, highlights the importance of prioritizing a timely referral for VAD implantation.

Patients with CHD are living longer, owing to medical and surgical advances. While reassuring, other clinical considerations have emerged, such as how to manage acute and unrelenting heart failure. Further, recent Cleveland Clinic-led studies have shown that CHD is a leading indication for heart failure-related hospitalization and readmissions.

Questioning the natural history of CHD

Pediatric heart failure and transplantation specialists like Dr. Amdani have been turning their attention toward these vexing issues in pediatric heart failure.

“As a community, we’ve excelled at improving care for patients with CHD by developing innovative approaches and technically challenging procedures. But are outcomes for those who develop advanced heart failure really improving?” questions Dr. Amdani.

Understanding this question—as well as the differences between univentricular and biventricular CHD patients—could offer insights into the best ways to manage advanced heart failure in children.

Dr. Amdani and colleagues utilized data from ACTION, a pediatric healthcare learning network dedicated to improving the lives of children with heart failure by focusing on collaborative learning and sharing best practices. Their primary aim was to evaluate differences in outcomes following VAD implantation in children with and without CHD. A secondary aim was to drill down on the CHD cohort data and evaluate potential outcome differences among disease subtypes: univentricular versus biventricular.

The study represents the largest outcomes analysis for children with CHD who are undergoing VAD implantation.

CHD cohort has worse survival, outcomes than non-CHD counterparts

The investigators examined 966 patients undergoing VAD implantation from April 2018 to February 2023. Of these, 36% (N=352) had CHD, and the majority, 65% (N=230), had univentricular CHD. Compared to their non-CHD counterparts, those with CHD were more likely to be younger, listed as INTERMACS, on mechanical ventilation, or be supported on ECMO preimplantation (P < 0.05 for all).

After VAD implantation, those with CHD were more likely to have worse survival and experience more adverse outcomes—including stroke, bleeding, infection, respiratory failure, and renal and hepatic dysfunction, the investigators report.

“That’s a problem,” exclaims Dr. Amdani. “Regardless of the adverse event in question, the rates were much higher for those with congenital heart disease.”

Debunking the univentricular heart myth

Interestingly, the analysis comparing children with univentricular and biventricular CHD revealed no significant clinical characteristics—except for a lower estimated glomerular filtration rate in children with univentricular CHD. Importantly, there were no survival differences after VAD implantation in children with univentricular CHD vs. biventricular CHD.

This counters some conventional thinking about outcomes for univentricular versus biventricular CHD, according to Dr. Amdani.

“The natural tendency is to think that the univentricular hearts are probably going to be higher risk, but when we risk adjusted everything in our multivariable models, we found that the survival outcomes were not different.”

Embracing more proactive referral practices

The takeaway when managing the CHD patient population, he says, is focusing on mitigating associated morbidities. He offers this may be remedied, in part, by a timelier referral for those with CHD who are experiencing worsening heart failure.

“We have to focus on reducing risk—the risk of stroke, bleeding, infection, respiratory failure, and end-organ dysfunction—and that may be a matter of reassessing our referral practices for patients who could benefit from advanced cardiac therapies.”