Experimental heart pump saves Alabama girl

Greer Underwood, 9, became the first child in the U.S. to get an experimental heart device in March, keeping her alive for a Mother’s Day heart transplant.

Nine-year-old Greer Underwood was healthy until February 2011. What seemingly began as sinusitis on a Tuesday became almost fatal by the weekend when her heart began to fail. Now, after a historic series of events at the University of Alabama at Birmingham, she’s the only child in the country to have used the experimental heart pump, Heartware, as a bridge to transplant.

Greer was transported Feb. 26 to Children’s Hospital of Alabama in Birmingham from her northwest Alabama hometown of Muscle Shoals and was diagnosed with severe heart failure from cardiomyopathy.

“Earlier that week, Greer just started feeling bad,” said her mother, Dawn Underwood. “She was really not sick-sick, just a cough, and we went to our local pediatrician. They thought it was sinusitis and sent us home with an antibiotic. The next day Greer’s breathing was labored, short shallow breaths, and we took her to the ER and they said it was pneumonia. They sent us home. Thursday we did breathing treatments, antibiotics and steroids, but Friday we still didn’t feel good about it so we went back to the ER. They said her blood sugar was really high and it was diabetes, and they were going to send us to Birmingham.”

Once she arrived in Birmingham it was clear that Greer wasn’t suffering from diabetes but something far more complicated — her heart was failing. UAB’s pediatric cardiologists, who provide cardiac care at Children’s, decided to transfer her to the adjacent UAB Hospital cardiac intensive care unit (CICU), where cardiac cases are handled.

Within an hour of arriving in the CICU, Greer suffered a stroke caused by a clot from her failing heart. The stroke was enormous, doctors said, and should have been life-ending, but UAB’s stroke-response team performed the standard adult stroke treatment — administration of the clot-busting drug TPA and extraction of the clot in the catheter lab within four hours of her stroke. Her doctors say both of these therapies, especially the clot extraction by catheter, are extremely rare in pediatrics — but without them she likely would have died or would have had significant neurological damage.

After removing the clot, doctors still had to manage her failing heart, which was working because of drugs alone. She became very unstable and required all-night resuscitation and maximum life support for days. Surgery was not a possibility because of the increased risk of stroke.

“Her stroke limited our treatment options initially,” said UAB cardiothoracic surgeon James Kirklin, M.D. “The drugs bought us some time. Two weeks after the stroke was a critical juncture because the major risk of having another from a surgical intervention had fallen to at least a reasonable level.”

Kirklin knew her heart needed to be supported with a ventricular-assist device (VAD), but the blood thinners used with the VAD approved for use in children, the Berlin Heart, increased the risk of bleeding in her brain because of her recent stroke.

“The Berlin Heart is a good device, but for her, it would not work,” Kirklin said. “If she had another small or medium-size stroke, it might be devastating for a child who has already had one in the past month. That inspired us to look for other alternatives.”

Kirklin examined all the available options. Fortunately, a new, third-generation VAD – Heartware – is being reviewed by the FDA for approval as a bridge to transplant for adults and is in clinical trials at UAB as a permanent device for adults. UAB’s institutional review board, the company that makes Heartware and the FDA all gave special permission for Greer to receive the pump, and she became the first child in the United States to be implanted with this device. It has been used three times in Europe in children.

“For her, any other adult pump was not an option because she was too small,” Kirklin said. “This is the smallest pump available and was a perfect solution for her for medium-term support.”

Greer, who received the Heartware VAD the first week of March, recovered amazingly well from the stroke, her doctors say. The device enabled her to be weaned from all cardiac and respiratory support. She had just completed occupational and physical therapy at Children’s Hospital for residual weakness from the stroke when a donor heart became available.

‘We got the call Saturday night, and Greer got her heart on Mother’s Day, May 8,” Dawn Underwood said. “It all happened so fast, but we are so grateful for everything the doctors have done for us. We feel blessed.”

Greer and her family stayed in Birmingham until early June while she recovered. Now that they have returned home to Muscle Shoals, Greer is looking forward to one thing — swimming in the family pool with her friends.

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