Improved outcomes with pulsatile paracorporeal ventricular assist device support in children: A single-center experience

Objective: The Berlin Heart EXCOR (BHE) remains the only long-term mechanical circulatory support option for small children, yet it carries a high risk of morbidity and mortality, most notably from cerebrovascular accidents (CVAs). This study evaluates how the outcomes of children supported with BHE changed with evolving management. Methods: All consecutive patients receiving BHE at our institution from 2009 to 2024 were included. Results: BHE support was used in 75 patients (median age 1 year). Median support duration was 128 days. Transplantation was achieved in 64% (48/75) of patients. BHE was removed because of recovery in 13.3% (10/75), and 21.3% (16/75) died while on BHE support. Overall survival was 87.7%, 80.9%, and 65.9% at 1, 6, and 12 months, respectively. Survival improved significantly after 2019 (hazard ratio, 0.14; 95% confidence interval, 0.03-0.72; P = .02), whereas the risk of death was greater in patients with CVA (hazard ratio, 3.08; 95% confidence interval, 0.99-9.47; P = .05). A total of 36 CVAs occurred in 23 patients (31%). Freedom from CVA at 1, 6, and 9 months was 81.8%, 67.5%, and 59.1%, respectively. Overall CVA incidence and freedom from CVA did not differ between eras, but fatal CVA incidence decreased (54% vs 10%, P = .03), coinciding with increased rate of successful outcomes (transplantation and explantation: 70.8% vs 92.6%, P = .03). Key differences between eras included the introduction of bivalirudin, decreased threshold for cannula/pump interventions (1.4 vs 5.8 per patient, P < .001), and more proactive timing of support, with fewer patients progressing to preimplantation cardiogenic shock (P = .02) and reduced pre-BHE extracorporeal membrane oxygenation (P = .04) and pre-BHE centrifugal pump support (P = .007). Conclusions: Modern BHE management significantly reduces incidence of fatal strokes and improves survival, despite increased duration of support.