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Ann Thorac Surg 1996;62:578-580
© 1996 The Society of Thoracic Surgeons

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Case Report

Biventricular Assist Device as a Bridge to Transplantation in a Pediatric Patient

Divisions of Cardiothoracic Surgery and Pediatric Cardiology, College of Physicians and Surgeons of Columbia University, New York, New York

Accepted for publication February 26, 1996.

	Abstract

Top Footnotes Abstract Introduction Comment Acknowledgments References

 
A 5-year-old boy with idiopathic cardiomyopathy and rapidly worsening hemodynamic parameters underwent placement of a biventricular assist device as a bridge to transplantation. Direct anastomoses to both the aorta and pulmonary artery with Dacron grafts attached to Carmeda-coated tubing facilitated the support period. Inflow was provided by right atrial appendage and left ventricular apex cannulas. A centrifugal pump provided support for 2 days until a suitable donor was identified. The technique is simple, reproducible, and effective for patients with small body surface areas.

	Introduction

Top Footnotes Abstract Introduction Comment Acknowledgments References

 
The use of ventricular assist devices (VAD) in the pediatric population has usually been reserved for postcardiotomy heart failure [1–4]. The use of VADs as a bridge to transplantation has been widely reported in the adult population [5–7], but its use in children is limited and has met with generally poor outcomes [4, 6, 8]. The use of biventricular assist devices as a bridge to transplantation is even more limited.

Reluctance on the part of surgeons to intervene in these cases has arisen in part from the limited device options available. The only Food and Drug Administration-approved device for long-term bridging to heart transplantation in the United States, the ThermoCardiosystems Heartmate (Woburn, MA), can only be implanted in patients whose body surface area is more than 1.5 m². Although this has allowed us to successfully salvage patients as young as 13 years old, smaller patients cannot be helped. The ABIOMED BVS5000 (Danvers, MA), a Food and Drug Administration-approved device for postcardiotomy failure, has also been used successfully in young teenagers, but the device must flow at least 3 L/min, making use in patients with a body surface area of less than 1.2 m² very difficult. At lower flows the thromboembolism incidence becomes prohibitively high without extra anticoagulation. Commercially available devices outside of the United States, including the Berlin heart, have provided satisfactory support in the pediatric population, although these pumps cannot be used by domestic surgeons.

We present another option for mechanical circulatory support, constructed from Food and Drug Administration-approved, widely available materials, that we have used successfully as a bridge to transplantation.

This 5-year-old boy with a body surface area of 0.69 m² first presented to his community hospital with complaints of a nonproductive cough associated with shortness of breath. Evaluation at that time revealed pulmonary edema secondary to severe congestive heart failure necessitating dobutamine, dopamine, and furosemide administration. An echocardiogram revealed dilated and hypokinetic left and right ventricles. Myocardial biopsy was significant for a lymphocytic infiltrate that was managed with one course of intravenous immunoglobulins and methylprednisolone. His was weaned off of inotropic support and later discharged home.

He did well for 1 month at which time he again required admission for inotropic support. His hemodynamics worsened requiring more aggressive management and he was transferred to our institution for an orthotopic heart transplantation. At this point he required 13 µg • kg^-1 • h^-1 of dobutamine and 3 µg • kg^-1 • h^-1 of dopamine.

While he was in the intensive care unit a massive pulmonary hemorrhage developed associated with oxygen desaturation, and he required intubation. The intubation was complicated by a bradycardia arrest with subsequent chest compressions. Bilateral pneumothoraces later developed, which were managed with chest tube placement. He became febrile and his hemodynamic instability worsened requiring further inotropic and pressor support. Ultimately he began to manifest signs of multiple organ system failure secondary to hypoperfusion. Although his inotropic support was maximized, he became persistently acidotic. At this point we decided that he should undergo placement of a biventricular assist device until a suitable donor became available.

A circuit was constructed by pulling a 8-mm collagen-coated Dacron (Hemashield, Meadox Medicals, Inc, Oakland, NJ) over a Carmeda-coated 0.25-inch Biomedicus tubing (Medtronic Blood Systems, Anaheim, CA) and fastening the two using umbilical tape; this connection was reinforced with sterile silicone type glue (catalog 890, Dow Corning, Midland, MI) (Fig 1). The Dacron grafts were sewn to the ascending aorta and pulmonary artery. Inflow to the left VAD was provided with a 14F Carmeda-coated DLP cannula (Grand Rapids, MI) inserted into the left ventricular apex. The same venous cannula was used in the right atrium for the right VAD. The cannulas were brought through stab wounds in the right and left upper quadrants and the patient was separated from cardiopulmonary bypass. The patient's chest was closed in the normal fashion after protamine was administered and hemostasis obtained.

View larger version (31K): [in this window] [in a new window]   Fig 1. . Method by which the inflow Dacron graft was fastened to the tubing using an umbilical tape. The Dacron graft is sewn to the ascending aorta or the pulmonary aorta.

Two days after biventricular assist device placement a suitable donor was identified. At the time of heart transplantation a white thrombus, which may have existed preoperatively, was identified in the pulmonary artery but not elsewhere. The donor heart ischemic time was 4 hours 40 minutes due to a 3-hour 30-minute travel time. Difficulty was encountered weaning the child off of bypass because of right heart failure and he required the aid of nitric oxide, norepinephrine, epinephrine, isoproterenol, milrinone, and nitroglycerin. He improved postoperatively and was extubated on the third day after transplantation.

His recovery was complicated by the evolution of a stroke. Head computed tomography revealed diffuse watershed ischemic changes in the left frontal, occipital, parietal, and right occipital and parietal lobes. In addition, he had a hemorrhagic area in the right occipital lobe. The stroke was thought to be a result of the low flow state that existed just before device implantation. No evidence for an embolic event existed. He was without any other complications and had excellent cardiac function. To date, he has only a mild residual right-sided weakness.

	Comment

Top Footnotes Abstract Introduction Comment Acknowledgments References

 
The case presented is significant for five reasons. First, by directly anastomosing the collagen-impregnated Dacron graft to the pulmonary artery and aorta we avoided the complications associated with cannula placement, primarily that of bleeding. This arrangement should also facilitate longer term VAD use, particularly in situations where it may be feasible to reduce sedation and allow patient mobilization. Pursestring-secured cannulas will often bleed if hypertension occurs; patient movement also may dislodge the cannula. In addition, one is not limited to using only commonly available cannulas.

Second, placement of the left VAD inflow into the left ventricular apex allowed for optimal decompression of the left ventricle. This lessens left ventricular distention, which could inhibit left ventricular recovery in the case of postcardiotomy use. This method reduces stasis, which helps prevent thrombus formation and subsequent embolization.

Third, the use of Carmeda-coated circuits has shown much promise in the laboratory [9, 10] although its clinical benefit has not been as clearly demonstrated [11]. This technology has the potential to avoid or reduce the use of anticoagulation, which would substantially lower the incidence of complications associated with VADs. In this particular case there was no thrombus found on the tubing or within the pump head. Although eventually the patient was maintained on heparin with an activated clotting time of 180 seconds, initially postoperatively no anticoagulation was given. At the time of his orthotopic heart transplant a white thrombus was found in the pulmonary artery, which appeared more than 2 days old; therefore, the thrombus most likely did not originate in the circuit.

Fourth, the method for connecting the tubing to the Dacron graft represents an effective and highly versatile technique for accomplishing an otherwise difficult and crucial aspect of the procedure. There did not appear to be any complications related to this technique.

Finally, this case represents one of the few reported cases of a biventricular assist device serving as a bridge to transplantation in a pediatric patient. Although the support period was quite short, this case suggests a possible alternative to a problem that is currently limited by the absence of small assist devices that are effective in children. Although some reports of potential totally implantable pediatric assist devices [12, 13] exist, until that technology is refined other options must be sought. Another clinically available option, extracorporeal membrane oxygenation, requires incorporation and maintenance of an oxygenator and often will result in hematologic complications during prolonged support. We present a feasible support system, especially in light of a severe shortage of pediatric heart donors; however, additional experience is needed to determine the applicability of this technique to a broad spectrum of patients.

	Acknowledgments

Top Footnotes Abstract Introduction Comment Acknowledgments References

 
Doctor Oz is an Irving Scholar of Columbia University.

	Footnotes

Top Footnotes Abstract Introduction Comment Acknowledgments References

 
Address reprint request to Dr Oz, Division of Cardiothoracic Surgery, Columbia-Presbyterian Medical Center, 171 Ft. Washington Ave, New York, NY 10032.

	References

Top Footnotes Abstract Introduction Comment Acknowledgments References

 

1. Matsuda H, Matsuwaka, Kaneko M, et al. Analysis of clinical factors for survival after left and biventricular bypass using centrifugal pump following open heart surgery in infants and adults. Artif Organs 1990;14:382–6.[Medline]
2. Pennington DG, Swartz MT. Circulatory support in infants and children. Ann Thorac Surg 1993;55:233–7.[Abstract]
3. Karl TR, Sano S, Horton S, Mee RBB. Centrifugal pump left heart assist in pediatric cardiac operations. J Thorac Cardiovasc Surg 1991;102:624–30.[Abstract]
4. Scheinin SA, Radovancevic B, Parnis SM, et al. Mechanical circulatory support in children. Eur J Cardiothorac Surg 1994;8:537–40.[Abstract]
5. Farrar DJ, Hill JD, Gray LA Jr, et al. Heterotopic prosthetic ventricles as a bridge to cardiac transplantation. N Engl J Med 1988;318:333–40.[Abstract]
6. Pennington DG, McBride LR, Kanter KR, et al. Bridging to heart transplantation with circulatory support devices. J Heart Transplant 1989;8:116–23.[Medline]
7. Bolman RM, Cox JL, Marshall W, et al. Circulatory support with a centrifugal pump as a bridge to cardiac transplantation. Ann Thorac Surg 1989;47:108–12.[Abstract]
8. Delius RE, Zwischenberger JB, Cilley R, et al. Prolonged extracorporeal life support of pediatric and adolescent cardiac transplant patients. Ann Thorac Surg 1990;50:791–5.[Abstract]
9. Arnander C, Olsson P, Larm O. Influence of blood flow and the effect of protamine on the thromboresistant properties of a covalently bonded heparin surface. J Biomed Mat Res 1988;22:859–68.[Medline]
10. Von Segesser LK, Lachat M, Galliano B, et al. Performance characteristics of centrifugal pumps with heparin surface coating. Thorac Cardiovasc Surg 1990;38:224–8.[Medline]
11. Bianchi JJ, Swartz MT, Raithel SC, et al. Initial clinical experience with centrifugal pumps coated with the Carmeda process. ASAIO J 1992;38:M143–6.[Medline]
12. Koppert E, Holfert GW, Dew PA, et al. Preliminary in vitro evaluation of the first neonatal total artificial heart. Trans Am Soc Artif Intern Organs 1991;36:M122–8.
13. Kaplon RJ, Oz MC, Kwiatkowski PA, et al. Jarvik 2000 ventricular assist device: a potential bridge to pediatric transplantation. Surg Forum 1994;45:268–70.

This article has been cited by other articles:

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				T. M. Dewey, J. M. Chen, T. B. Spanier, and M. C. Oz Alternative technique of right-sided outflow cannula insertion for right ventricular support Ann. Thorac. Surg., November 1, 1998; 66(5): 1829 - 1830. [Abstract] [Full Text] [PDF]

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Jan M. Quaegebeur Mehmet C. Oz Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Williams, M. R. Articles by Oz, M. C. Search for Related Content PubMed PubMed Citation Articles by Williams, M. R. Articles by Oz, M. C.