Systemic ventricular assist device support in Fontan patients: A report by ACTION

• Published in: The Journal of heart and lung transplantation Vol. 40; no. 5; pp. 368 - 376
• Main Authors: Cedars, Ari, Kutty, Shelby, Danford, David, Schumacher, Kurt, Auerbach, S.R., Bearl, D., Chen, S., Conway, J., Dykes, J.C., Jaworski, N., Joong, A., Lorts, A., Mascio, C.E., Morales, D.L.S., Niebler, R.A., O'Connor, M., Peng, D.M., Philip, J., Reichman, J.R., Rosenthal, D.N., Zafar, F., VanderPluym, C., Villa, C., Zinn, M.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-05-2021
• Subjects: Adolescent; Child; Child, Preschool; congenital heart disease; end-stage heart failure; Female; Follow-Up Studies; Fontan; Fontan Procedure; Heart Failure - surgery; Heart Transplantation; Heart-Assist Devices; Humans; Male; mechanical circulatory support; Registries; Retrospective Studies; Treatment Outcome; ventricular assist device; ventricular assist device; mechanical circulatory support; congenital heart disease; end-stage heart failure; Fontan
• ISSN: 1053-2498; 1557-3117
• DOI: 10.1016/j.healun.2021.01.011

The size of the Fontan population with end-stage heart failure is growing. In this population, heart transplantation has been the only option. This study sought to investigate the efficacy of ventricular assist device (VAD) support in Fontan patients.
We conducted a retrospective study of Fontan patients in the Advanced Cardiac Therapies Improving Outcomes Network. We evaluated patient characteristics, and the clinical and physiologic outcomes after VAD implantation.
We identified 45 Fontan patients implanted with VAD. The average age of patients was 10 years (interquartile range: 4.5–18) and 30% were female. The majority had a morphologic right ventricle (69%), moderate or greater ventricular dysfunction (83%), and moderate or greater atrioventricular valve regurgitation (65%). The majority of implants were as a bridge to transplantation (76%), and the majority of patients were Interagency Registry for Mechanically Assisted Circulatory Support Profile 2 (56%). The most commonly employed device was the Medtronic HeartWare HVAD (56%). A total of 13 patients were discharged on device support, and 67% of patients experienced adverse events, the most common of which were neurologic (25%). At 1 year after device implantation, the rate of transplantation was 69.5%, 9.2% of patients continued to be VAD supported, and 21.3% of patients had died. Hemodynamically, VAD was effective in decreasing both Fontan and ventricular end-diastolic pressures in some individuals.
VAD is effective in supporting patients with end-stage Fontan failure awaiting heart transplantation. Future research should focus on identifying clinical and physiologic characteristics predictive of a favorable response to VAD support.