Anemia is a predictor of morbidity and mortality in both pediatric and adult patients with heart failure. This risk is increased in patients who require ventricular assist device (VAD) placement. The most common mechanism suggested for why these patients develop anemia is chronic inflammation caused by the immune system reacting to the VAD components. The inflammatory response that occurs can suppress erythropoiesis by inhibiting production of erythropoietin. Studies have demonstrated that anemic VAD patients have lower-than-expected erythropoietin levels, which leads to the consideration of erythropoiesis-stimulating agents (ESAs) in this population. Therapy with ESAs can increase hemoglobin and hematocrit levels, thereby decreasing the need for transfusions, subsequently reducing the risk of anti–human leukocyte antigen antibody development. Concerns that ESAs may increase the risk of thrombotic complications in a population already plagued with physiologic disturbances due to the VAD device remain a main barrier in routine use of these medications. The goal of this case series is to discuss a single center's experience with epoetin alfa in pediatric VAD patients at an academic children's hospital. A total of 4 patients were included with no evidence of adverse effects during a total of 120 patient-days of epoetin therapy. One patient was able to discontinue ESA therapy secondary to robust improvement in cell line counts at the time of discharge, while the other 3 patients received heart transplant prior to the discontinuation of ESA therapy. An increase in hematocrit of 1% to 5.5% was seen from epoetin initiation to discontinuation.

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