Management of Single‐Ventricle Patients With Berlin Heart EXCOR Ventricular Assist Device: Single‐Center Experience

Abstract

There are minimal data regarding chronic management of single-ventricle ventricular assist device (VAD) patients. This study aims to describe our center's multidisciplinary team management of single-ventricle patients supported long term with the Berlin Heart EXCOR Pediatric VAD. Patient #1 was a 4-year-old with double-outlet right ventricle with aortic atresia, L-looped ventricles, and heart block who developed heart failure 1 year after Fontan. She initially required extracorporeal membrane oxygenation support and was transitioned to Berlin Heart systemic VAD. She was supported for 363 days (cardiac intensive care unit [CICU] 335 days, floor 28 days). The postoperative course was complicated by intermittent infection including methicillin-resistant Staphylococcus aureus, intermittent hepatic and renal insufficiencies, and transient antithrombin, protein C, and protein S deficiencies resulting in multiple thrombi. She had a total of five pump changes over 10 months. Long-term medical management included anticoagulation with enoxaparin, platelet inhibition with aspirin and dipyridamole, and antibiotic prophylaxis using trimethoprim/sulfamethoxazole. She developed sepsis of unknown etiology and subsequently died from multiorgan failure. Patient #2 was a 4-year-old with hypoplastic left heart syndrome who developed heart failure 2 years after bidirectional Glenn shunt. At systemic VAD implantation, he was intubated with renal insufficiency. Post-VAD implantation, his renal insufficiency resolved, and he was successfully extubated to daytime nasal cannula and biphasic positive airway pressure at night. He was supported for 270 days (CICU 143 days, floor 127 days). The pump was upsized to a 50-mL pump in May 2011 for increased central venous pressures (29 mm Hg). Long-term medical management included anticoagulation with warfarin and single-agent platelet inhibition using dipyridamole due to aspirin resistance. He developed increased work of breathing requiring intubation, significant anasarca, and bleeding from the endotracheal tube. The family elected to withdraw support. Although both patients died prior to heart transplantation, a consistent specialized multidisciplinary team approach to the medical care of our VAD patients, consisting of cardiothoracic surgeons, heart transplant team, hematologists, pharmacists, infectious disease physicians, psychiatrists, specialty trained bedside nursing, and nurse practitioners, allowed us to manage these patients long term while awaiting heart transplantation.

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“…Complications are mainly the result of the paracorporeal placement, with an increasing number of driveline infections and thrombosis of the very huge pumps. 7,8 The HeartWare pump (HeartWare, Framingham, MA, USA) also can be successfully implanted into both ventricles. 9 Problems with this pump, as with LVAD systems, are gastrointestinal bleeding (13%), bleeding that requires reoperation in 15% of the cases, and driveline infections due to the abdominal exit (17% in 1 y).…”

An overview of mechanical circulatory support in single-ventricle patients

“…Others have noted the benefits of a multidisciplinary approach consisting of surgeons and heart failure specialists, intensivists, hematologists, pharmacists, nurses and potentially psychiatrists and infectious disease physicians (72). We feel this is absolutely necessary to optimize the outcomes of these very difficult patients.…”

Mechanical circulatory support for the failing functional single ventricle

“…Experience with MCS in failing FSV patients has been reported by other teams, mostly in the form of case reports (2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)…”