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J Thorac Cardiovasc Surg 1997;114:505-507
© 1997 Mosby, Inc.

BRIEF COMMUNICATIONS

SUCCESSFUL BRIDGING TO CARDIAC TRANSPLANTATION IN A DYSTROPHIC INFANT WITH THE USE OF A NEW PARACORPOREAL PNEUMATIC PUMP

Meunster, Germany

Address for reprints: Michael Weyand, MD, Westfaelische Wilhelms Universitaet Muenster, Albert Schweitzer Straße 33, 48129 Muenster, Germany.

During the past decade, treatment of end-stage cardiac failure in adult patients with different forms of paracorporeal or implantable mechanical assist devices used as bridges to transplantation has become routine in many centers throughout the world. Survival after bridging and consecutive heart transplantation is comparable with that of nonbridged recipients if mechanical assistance lasts long enough to allow complete recovery of secondary organ dysfunction. However, no such mechanical assist device was available for neonates and smaller infants because of size incompatibility until recently. ^1-3 We report on our first experience with the MEDOS HIA system (MEDOS GmbH, Steinfurth, Germany) as a bridge to cardiac transplantation in a dystrophic infant, followed by successful cardiac transplantation.

A female child weighing 3490 gm was born on June 6, 1996. Delivery (Apgar scores at 1, 5 and 10 minutes were 10) and the early postpartum period was uneventful. At the age of 9 weeks, however, the child began having fever, shortness of breath, and sinus tachycardia. A chest x-ray film demonstrated right lower lobe infiltration suggestive of pneumonia but, more important, a silhouette of a huge heart. After referral to our institution, echocardiography confirmed massive enlargement of both ventricles. Left ventricular fractional shortening was calculated as 8%. Because she was in New York Heart Association class III-IV, the child was treated with digitalis, diuretics, and supportive oxygen at first. However, as the child's condition deteriorated further, with weight loss despite hypercaloric feeding and requirement of intravenous dopamine and dopexamine, she was listed for cardiac transplantation. The diagnosis was dilative cardiomyopathy, because no evidence of viral myocarditis was obtained. After 5 months on the waiting list, the child (3400 gm) had two episodes of cardiovascular collapse necessitating external heart massage and high-dose catecholamine support, as well as intubation and mechanical ventilation. Because no donor heart was available, the decision was made to use the paracorporeal MEDOS HIA system. Normothermic extracorporeal circulation was established with the use of a single atrial cannula. The arterial cannula was inserted into the proximal part of the aortic arch, leaving the ascending aorta untouched for the assist device. With the heart beating, a right-angled 18F venous cannula was placed into the left atrium via the intraatrial groove, secured by two purse-string sutures of 5-0 monofilament polypropylene. ^4,5 The cannula was tunneled below the right costal margin to exit the skin in the right epigastrium. The arterial 18F cannula was connected to the ascending aorta via a 4 mm polytetrafluorethylene graft, which exited the skin in the left epigastrium. After meticulous deairing, both tubes were connected to the 10 ml paracorporeal ventricle placed onto the abdominal wall. The air driveline was connected to the console, left ventricular assist was started at a fixed rate of 70 beats/min, and extracorporeal circulation was stopped. The initial settings of the pump allowed for a pump output of 700 ml/min, which corresponded to a cardiac index of 3 L/min per square meter. Hemostasis was achieved and the chest closed by a polytetrafluoroethylene membrane sutured to the skin, because closure of the sternum was not possible (Fig. 1).

View larger version (44K): [in this window] [in a new window]   Fig. 1. Comparative depiction of the 18F inflow cannula (left), the 10 ml pump chamber (center), and the outflow cannula with its attached 4 mm polytetrafluoroethylene conduit (right) used in our case.

After 14 days of mechanical support, a donor heart from a child with intracranial bleeding was procured. Total orthotopic transplantation with bicaval and pulmonary vein anastomoses was performed with moderate hypothermia with a graft ischemic time of 195 minutes. The postoperative clinical course was uneventful, based on standard triple-drug immunosuppression with cyclosporine, azathioprine, and steroids. Daily echocardiographic studies demonstrated sufficient and later continuously improving right ventricular function. Initial inotropic support could be reduced within 1 day and withdrawn within 1 week of support. Within a follow-up of 4 weeks, no episodes of rejection or infection were evident. On postoperative day 30, hemiplegia had almost completely resolved and the infant was discharged to her home with weight gain and increasing physical activity.

The experience of mechanical support in infants is small and restricted to few centers in Europe. To our knowledge, this is the first report ever dealing with a successful bridging procedure in an infant with the weight and size of a neonate. The MEDOS HIA ventricular assist device is a pneumatic diaphragm pump completely made of polyurethane, including the inflow and outflow valves that house in a conduit simulating the aortic sinuses. Pump chambers are available at volumes of 9 and 10 ml, at 22.5 and 25 ml, and at 54 and 60 ml, respectively, for right and left or biventricular support for neonatal, infant, or adult patients. Both inflow and outflow conduits are simple to place into the left atrium and the ascending aorta. Removal at the time of transplantation is similarly easy to achieve. In summary, the new MEDOS HIA system seems to offer a reliable instrument for mechanical support, even in neonates, when hemodynamic stability cannot be maintained by other means.

Footnotes

From the Departments of Cardiothoracic Surgery,^a Pediatric Cardiology,^b and Anesthesia and Operative Intensive Care,^c Westfaelische Wilhelms Universitaet Muenster, Muenster, Germany.

References

1. Rakhorst G, Hensens AG, Verkerke GJ, Blanksma PK, Bom VJJ, Elstrodt J, et al. In-vivo evaluation of the HIA-VAD: a new German ventricular assist device. Thorac Cardiovasc Surg 1994;42:136-40. [Medline]
   
2. Eilers R, Harbott P, Reul H, Rakhorst G, Rau G. Design improvements of the HIA-VAD based on animal experiments. Artif Organs 1994;18:438-73.
   
3. Tandler R, Deng MC, Schmid C, Scheld HH. Novacor LVAD bridge to transplantation in peripartum cardiomyopathy. Eur J Cardiothorac Surg. In press.
   
4. Scheld HH, Hammel D, Schmid C, Weyand M, Deng MC, Möllhoff T, et al. Beating heart implantation of a wearable Novacor left-ventricular assist device. Thorac Cardiovasc Surg 1996;44:62-6. [Medline]
   
5. Weyand M, Hammel D, Hoffmeier A, Loeher A, Frye K. Kerber S, et al. Erfahrungen mit dem tragbaren Links-Herz-Unterstützungssystem NOVACOR N 100. Transplantationsmedizin 1994;6:245-52.
   

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This Article 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): Michael Weyand Christof Schmid Hans H. Scheld Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Weyand, M. Articles by Scheld, H. H. Search for Related Content PubMed PubMed Citation Articles by Weyand, M. Articles by Scheld, H. H.