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Bridging to Transplant in Children Weighing 20-40 kg: Outcomes and Cost Comparison of Berlin Heart EXCOR and Intracorporeal Ventricular Assist Devices
Jaimin Trivedi, Toyokazu Endo, Deborah Kozik, Bahaaldin Alsoufi
Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Louisville, KY
Background: Ventricular assist device support (VAD) in children listed for heart transplantation (HT) is limited by patient size. Although the Berlin Heart EXCOR is available across all sizes, its extracorporeal design is associated with reduced mobility, prolonged hospitalization, and morbidity. Use of adult intracorporeal devices (I-VAD) has expanded to selected children. We compare clinical outcomes and costs of Berlin versus I-VAD in children weighing 20-40 kg who could be eligible for either strategy.
Methods: Children weighing 20-40 kg bridged to HT with VAD were identified by linking the United Network for Organ Sharing (UNOS) and Pediatric Health Information System (PHIS) databases, enabling combined clinical and cost analyses. During the study period (2016-2025), patients were stratified by device type into Berlin (n=41) and I-VAD (n=79) groups. Outcomes and costs were compared using logistic and regression analyses.
Results: Baseline characteristics are summarized in the table. Patients supported with Berlin were younger and weighed less; sex, race, and blood type distributions were similar between groups. Dilated cardiomyopathy was the underlying cause for listing for both Berlin (53.7%) and I-VAD (67.1%) (p=0.2693). Pre-transplant use of inotropes, dialysis, extracorporeal membrane oxygenation, and mechanical ventilation did not differ. Berlin Heart patients were more likely to receive total parenteral nutrition (87.8% vs. 54.4%, p=0.0003) and to be treated for all-cause infection (92.7% vs. 65.8%, p=0.0013). Although all patients were listed as Status 1A, waitlist duration was longer in the Berlin group (141 vs. 74 days, p=0.0352). Waitlist mortality between the two groups was similar (Berlin 6% vs. I-VAD 5%, p=0.35). Post-transplant operative mortality and complication rates were similar between groups; however, postoperative length of stay was longer in the Berlin group (26 vs. 19 days, p=0.0008). Adjusted hospitalization costs were significantly higher for Berlin support ($1.5 million vs. $0.4 million, p<0.001). Overall post-transplant survival was comparable between groups (92% vs. 87% At 5 years, p=0.8576).
Conclusion: In children weighing 20-40 kg, both Berlin and I-VAD provide acceptable survival to transplant. I-VAD support may offer advantages in cost and opportunities for discharge and rehabilitation. Device selection should be individualized based on patient pathology, size, anatomy, and clinical factors, and these findings may inform this complex decision-making process.
Figure: Table with Patient Characteristics (Left). Post-Transplant Survival Curve (Right)
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