Pediatric VAD Survival Improves Despite Rising Patient Complexity

Nearly 1,500 children with end-stage heart failure received ventricular assist devices (VADs) across North America in the past 13 years, and survival continues to improve. That is a central finding from the newest Society of Thoracic Surgeons−Pedimacs Report, which analyzed data from 38 hospitals.

Even as VAD support is being extended to sicker children and those with more complex anatomy, one-year survival has risen steadily, from 67% in 2012-2015 to 71% in 2016-2020 and 78% in 2021-2024.

The gains reflect both advances in device technology and major improvements in pediatric heart failure care, according to the report’s lead author, Shahnawaz Amdani, MD, Section Head of Pediatric Heart Function and Transplant at Cleveland Clinic.

About Pedimacs

Pedimacs, the Pediatric Interagency Registry for Mechanical Circulatory Support, was established in 2012 as a national prospective registry of patients younger than 19. It captures use of both durable and temporary VADs and offers an important real-world view of outcomes for children with advanced heart failure in the U.S.

“The recent report highlights how pediatric VAD care is being extended to children with increasingly complex heart anatomy and physiology,” says Dr. Amdani. “Nearly three in four patients are on enteral or parenteral nutrition before receiving a VAD, underscoring how ill many of these children are at the time of implant.”

Key findings from the report

Several trends stand out in the latest analysis:

• Cardiomyopathy remains the most common diagnosis, accounting for 57% of cases.
• Congenital heart disease (CHD) accounts for 28% of all implants, up from 20% in earlier eras.
• Among patients with CHD, 61% have single-ventricle physiology.
• Infants now make up a much larger share of VAD recipients: 40% of patients implanted in 2021-2024 were younger than 1 year, compared with 21% in 2012-2015.

For pediatricians, these findings underscore an important shift: VAD therapy is increasingly being used in younger, more medically fragile children, including those with congenital and single-ventricle heart disease.

Best and worst outcomes

Overall survival on device was 77% at six months and 73% at one year.

Outcomes were best among:

• Adolescents ages 11 to 19
• Children with cardiomyopathy
• Patients receiving implantable continuous-flow devices

Outcomes were poorest among:

• Infants younger than 1 year
• Children with CHD, especially those with single-ventricle physiology
• Patients in critical cardiogenic shock (Intermacs profile 1)
• Children needing ECMO before VAD implantation

“These patients have lower transplant rates and higher mortality,” Dr. Amdani notes. “Still, overall survival has improved over time, even as more infants and children with CHD are being supported. Much of this progress reflects better systems of care.”

He credits the ACTION (Advanced Cardiac Therapies Improving Outcomes Network) collaborative with helping standardize anticoagulation, blood pressure management, perioperative care and post-implant management.

“Most pediatric heart centers perform fewer than 10 VAD implants each year,” Dr. Amdani says. “Yet outcomes have improved, suggesting that front-line teams are increasingly equipped to care for these complex patients. Collaboration among centers has been essential to identifying and spreading best practices, even at lower-volume programs.”

A persistent device gap for smaller children

Implantable continuous-flow devices are now the most commonly used VADs in pediatric patients. These devices are associated with better outcomes and often make discharge possible. Among children supported with implantable continuous-flow devices, 51% were discharged, and 94% of those patients went home.

“Nearly all children with implantable continuous devices who were discharged were able to go home, which is a major win in pediatrics,” Dr. Amdani says.

But important limitations remain. Children weighing less than 30 kg often do not have access to appropriately sized intracorporeal devices. As a result, many still require paracorporeal support, which carries higher risks of thrombosis, bleeding, infection and neurologic complications.

“The best outcomes with VAD support are seen in children who can leave the hospital, return to their communities, attend school and participate in physical, nutritional and psychosocial rehabilitation,” Dr. Amdani says. “Children who remain hospitalized do not have the same opportunities.”

The withdrawal of the HeartWare™ HVAD™ system from the U.S. market — due to adult data — has further narrowed options for smaller children, many of whom are now limited to paracorporeal devices and prolonged hospitalization.

“These patients lose the opportunity for discharge,” Dr. Amdani says. “They often must remain in the hospital on VAD support, which increases the risk of hospital-acquired infection and other complications.”

BiVAD support: Greater need, poorer outcomes

The report also takes a close look at biventricular assist device (BiVAD) support, an area of growing importance and ongoing challenge.

Key findings include:

• One in five (20%) patients who initially received a left ventricular assist device (LVAD) ultimately required BiVAD support.
• Approximately 95% of right ventricular assist devices were placed within seven days of LVAD implantation, most during the initial operation, highlighting the importance of early perioperative right ventricular failure.
• Patients requiring BiVAD support were generally sicker before implant. They were more likely to be Intermacs profile 1, have CHD or restrictive cardiomyopathy, have a history of cardiac surgery, and require mechanical ventilation.
• Survival was substantially lower with BiVAD support than with LVAD support alone. Survival was 60% vs. 84.2% at six months, and 43.6% vs. 81.7% at one year.

“These findings point to the need for earlier recognition of right ventricular failure risk,” Dr. Amdani says. “They call for a high index of suspicion and proactive right ventricular support.”

He adds that poorer BiVAD outcomes likely reflect both greater preimplant acuity and limitations in currently available right-sided support strategies.

“We do not have dedicated pediatric right ventricular support devices, so we often adapt left-sided devices in ways that may not optimally support right ventricular function,” he says. “Innovation in device therapy, better predictive models for right ventricular failure and more tailored perioperative planning are all needed for these patients.”

Recovery is becoming a more important goal

Recovery is emerging as a more realistic and intentional goal in pediatric VAD care. Increasingly, VAD support is being used as a bridge to candidacy, allowing time for rehabilitation while clinicians assess whether transplantation or myocardial recovery is possible.

As bridge-to-recovery cases increase, future trials may help establish standardized approaches to serial heart function assessment. They also may help determine when VAD explant may be appropriate.

“For pediatric patients, delaying transplantation by even five to seven years can meaningfully extend life expectancy,” Dr. Amdani says. “Helping children recover with their native hearts for as long as possible is an opportunity we should not overlook.”