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Bridging the gap - mechanical support could increase survival of children requiring heart transplantation (pp 1948, 1967)

December 10, 2003

Embargoed 0001 h (London time) 12 December 2003.

Fewer children should die while waiting for a heart transplant if they are given mechanical heart support before transplantation, conclude authors of a UK study in this week's issue of THE LANCET.

Short-term mechanical heart support has potential for aiding children requiring heart transplantation. In adults the issues are different because there is a greater imbalance between the number of hearts available and needed, which leads to much longer waiting times. Allan Goldman from Great Ormond St Hospital, London, UK, and colleagues assessed the effect of mechanical assist devices at two UK centres (Great Ormond St Hospital, London, and the Freeman Hospital, Newcastle) for children with end-stage cardiomyopathy awaiting heart transplantation.

Over a five-year period (Jan 1998-Dec 2002) 22 children (average age 5.7 years) with end-stage cardiomyopathy were supported by a mechanical assist device as a bridge to first heart transplantation. Just over three-quarters of these children ( 77%) survived to hospital discharge, a much higher proportion than if they had remained on the waiting list without mechanical bridging support.

Nine children were supported by an external mechanical heart (paracorporeal ventricular assist device), and 13 were supported by an artificial heart and lung device (extra-corporeal membrane oxygenation (ECMO). Children were prioritised on the waiting list-this resulted in an average waiting time for a heart of 7.5 days.

Allan Goldman comments: "Our findings suggest that a national mechanical assist programme to bridge children to transplantation can minimise the number dying while on the heart transplant waiting list. In the context of urgent listing and a short waiting time, extra-corporeal membrane oxygenation seems to provide the safest form of support."

In an accompanying Commentary (p 1948), Mark Boucek from The Children's Hospital, Denver, USA, concludes: "Our ability to immunise against the infectious agents that can lead to acute heart failure is limited. Additionally, patients with familial and non-familial cardiomyopathy are also at risk. At present, we are not able to prevent acute heart failure in children. Goldman and colleagues' use of a dual strategy of mechanical circulatory support and urgent listing for transplantation offers a lifeboat for occupants of a rapidly sinking ship. But of course a lifeboat does not guarantee rescue. Only a more readily available supply of donor organs can provide the assurance of a rescue procedure for children with acute heart failure."

Lancet