Successful cardiac transplant after Berlin Heart bridge in a single ventricle heart: Use of aortopulmonary shunt as a supplementary source of pulmonary blood flow
2008; Elsevier BV; Volume: 137; Issue: 1 Linguagem: Inglês
10.1016/j.jtcvs.2008.02.044
ISSN1097-685X
AutoresF. Bennett Pearce, James K. Kirklin, William L. Holman, Cindy Barrett, Robb L. Romp, Yung R. Lau,
Tópico(s)Cardiac Structural Anomalies and Repair
ResumoPulsatile ventricular assist devices, and in particular the Berlin Heart Excor infant ventricular assist device (Berlin Heart; Berlin Heart AG, Berlin, Germany), have rarely been used to support infants and small children with single ventricle.1Chu M.W. Sharma K. Tchervenkov C.I. Jutras L.F. Lavoie J. Shemie S.D. et al.Berlin Heart ventricular assist device in a child with hypoplastic left heart syndrome.Ann Thorac Surg. 2007; 83: 1179-1181Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar, 2Nathan M. Baird C. Fynn-Thompson F. Almond C. Thiagarajan R. Laussen P. et al.Successful implantation of a Berlin Heart biventricular assist device in a failing single ventricle.J Thorac Cardiovasc Surg. 2006; 131: 1407-1408Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar We report successful cardiac transplantation in an infant with single ventricle supported with a Berlin Heart. A 15-month-old boy with the diagnosis of {S,D,D} double-outlet right ventricle, mitral valve atresia, d-malposition of the great vessels, status-post pulmonary artery band in infancy, and poor systemic ventricular function was referred for transplant evaluation. A catheterization performed at the referral institution 3 months before admission documented mean central venous pressure of 25 mm Hg, poor systemic ventricular function with severe atrioventricular valve regurgitation, and bilateral iliac vein thrombosis. At the time of arrival he was intubated, receiving infusions of dopamine, epinephrine, and milrinone. His examination was notable for anasarca. Vitals signs on admission were as follows: pulse 135 beats/min, blood pressure 75/54 mm Hg, weight 8.3 kg, and systemic oxygen saturation 87%. Laboratory data demonstrated arterial lactate 2 μMol/l, blood urea nitrogen 40 mg/dL, creatinine 0.8 mg/dL, total bilirubin 3.4 mg/dL, aspartate aminotransferase 1453 μMol/l, and gamma glutamyl transferase 58 μMol/l. Because of worsening circulatory and end-organ status, extracorporeal membrane oxygenation (ECMO) was initiated on hospital day 16. Cannulas, 8F arterial and 12F venous, were placed in the right common carotid artery and right internal jugular vein, respectively. Cannula positions were confirmed with echocardiography. ECMO flow was adjusted to maintain mixed venous oxygen saturation 75% to 80%. The patient responded with decreasing liver enzymes, increased urine output, partial resolution of edema, and reduction in central venous pressure to 14 to 16 mm Hg. After 3 days of ECMO support complicated by progressive hemolysis, a 25-mL Berlin Heart left ventricular assist device was implanted. At operation, the patient was converted from ECMO to cardiopulmonary bypass. For Berlin Heart implantation the pulmonary artery was ligated distal to the pulmonary artery band and a 5-mm polytetrafluoroethylene shunt (Gore-Tex shunt; W. L. Gore & Associates, Inc, Flagstaff, Ariz) was placed from the ascending aorta to the right pulmonary artery. Cannulas were placed in the right atrium and ascending aorta inferior to the shunt (Figure 1). The right internal jugular vein and the right common carotid artery were repaired. At the conclusion of the procedure, systemic arterial saturation was 60% to 65%. The pulmonary artery ligature was removed, the pulmonary band being left in place as a second pathway for pulmonary blood flow. Systemic arterial saturation was 75% to 80% after this. Delayed sternal closure was done 48 hours later. Berlin Heart support was maintained for 7 weeks until a suitable organ was available. The patient was extubated. He received physical therapy and enteral feeds. He was active, maintaining oxygen saturations of 65% to 85% with supplemental oxygen. End-organ function normalized. Echocardiography confirmed antegrade pulmonary blood flow and flow through the polytetrafluoroethylene shunt. Anticoagulation was started on postoperative day 2. Unfractionated heparin, warfarin, clopidogrel, and aspirin were used. Heparin was discontinued when the international normalized ratio reached the target range of 2.5 to 3.5. There were no thrombotic or hemorrhagic complications. Transplantation was carried out with a recipient/donor weight ratio of 0.92. The panel reactive antibody was 0. After discontinuation of cardiopulmonary bypass, the pulmonary artery pressure was one half the systemic pressure. Transesophageal study showed dilation of the right ventricle with focal reduction in right ventricular systolic function. The central venous pressure was 19 to 20 mm Hg for the first 24 hours postoperatively during support with nitric oxide, nitroglycerin, and prostaglandin infusions. Right ventricular function on echocardiography improved commensurate with decrease central venous pressure to the 12 mm Hg range and extubation on day 8. Catheterization with biopsy was done on postoperative day 35. The reconstructed right internal jugular vein was used for vascular access. The right heart pressures were mildly elevated and histologic examination demonstrated no rejection. The patient was discharged several days later. The patient remains well without graft dysfunction or rejection 2 months after transplantation. The Berlin Heart provides long-term support, consuming fewer blood products and allowing extubation and reversal of debilitation not possible with ECMO.3Stiller B. Hetzer R. Weng Y. Hummel M. Hennig E. Nagdyman N. et al.Heart transplantation in children after mechanical circulatory support with pulsatile pneumatic assist device.J Heart Lung Transplant. 2003; 22: 1201-1208Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar, 4Stiller B. Lemmer J. Merkle F. Alexi-Meskishvili V. Weng Y. Hubler M. et al.Consumption of blood products during mechanical circulatory support in children: comparison between ECMO and a pulsatile ventricular assist device.Intensive Care Med. 2004; 30: 1814-1820Crossref PubMed Scopus (71) Google Scholar Use of the Berlin Heart in infants with single ventricle physiology has been rarely reported with no reports of successful transplantation to hospital discharge.1Chu M.W. Sharma K. Tchervenkov C.I. Jutras L.F. Lavoie J. Shemie S.D. et al.Berlin Heart ventricular assist device in a child with hypoplastic left heart syndrome.Ann Thorac Surg. 2007; 83: 1179-1181Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar, 2Nathan M. Baird C. Fynn-Thompson F. Almond C. Thiagarajan R. Laussen P. et al.Successful implantation of a Berlin Heart biventricular assist device in a failing single ventricle.J Thorac Cardiovasc Surg. 2006; 131: 1407-1408Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar Provision of systemic and pulmonary circulation with a single ventricular assist device is challenging. The technique we describe worked well in our case and may be useful in similar situations.
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