Aggressive Use of Ventricular Assist Devices Improves Survival in Infants with Failing Single Ventricle Congenital Heart Disease
Ryan R. Davies1, Nicholas Andersen1, Karl REyes1, Jodie Thomason2, Ryan Butts1
1The University of Texas Southwestern Medical Center, Dallas, TX, 2The University of Texas Southwestern Medical Center, Dallas, TX
Background: Failing single ventricle (SV) physiology either before or early following 1st stage palliation is an increasingly frequent indication for heart transplantation. Waitlist mortality in these patients is high and waitlist times are increasing; . We hypothesized that a more aggressive approach to early use of single ventricle ventricular assist devices (SVADs) would improve survival before and after transplantation.
Methods: Single-center retrospective chart review of SV patients < 10kg (2017-2025) who underwent first-stage SV palliation but were not candidates for subsequent palliation. The primary outcome was long-term survival following initial palliation independent of transplantation. Patients were stratified by SVAD use and by era (early: 2017-2021, late: 2022-2025; based on a more aggressive approach to SVAD use in SV patients occurring in 2022).
Results: Sixty-one SV patients (3.0kg, IQR 2.5-3.5) underwent 1st stage palliation at a median of 8 days (IQR 3-14) without subsequent 2nd stage (early: 27, late: 34). SVADs were implanted in 26 patients. SVADs were more common in the late era (23/34 [67.6%], 3/27 [11.1%], p< 0.0001). Pulmonary blood flow on SVAD included mBTTS (n=17), VAD outflow y-graft (n=2), or a PDA (n=7). VAD implant occurred 13 days (0-225) following stage 1 palliation at median size 3.6kg (2.3-9.3). ECMO after initial palliation was common in both groups (SVAD: 14, 53.3% vs. no VAD:13, 37.1%, p=NS).
Overall survival following initial palliation was higher in the SVAD era (Figure A, p<0.0001) and higher among SVAD patients (70.9% vs. 35.6% at 1 yr, p=0.0112) and. Patients on SVADs were also more likely to be transplanted (OR 2.7, 95% 1.5-5.1). Median days from stage 1 to transplant were 161 in SVAD patients and 110 in non-SVAD patients (p=0.17). Competing risks demonstrated more patients alive or transplanted at 1 year following palliation among the SVAD patients (Figure B, 80.1% vs. 41.9%, p=0.0056).
Conclusion: Patients with failing SV physiology have better outcomes, including transplantation and long-term survival, when palliation includes aggressive use of SVAD support.
Kaplan-Meier survival estimates following birth among single ventricle patients, comparing (A) overall survival by era and (B) competing risks of alive or transplanted by VAD vs. no VAD
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