Use of a Left Ventricular Assist Device as a Bridge to Transplantation in a Pediatric Patient

Tex Heart Inst J. 1989;16(1):46-50.

Abstract

Despite many advances in heart transplantation and in mechanical circulatory support, the benefits of staged cardiac transplantation have not been extended to the pediatric transplant recipient, chiefly because implantable circulatory assist devices are still too large. Extracorporeal devices, however, can overcome this impediment. Here we report the 1st case, to our knowledge, in which an extracorporeal left ventricular assist device has been used in a child to support circulation prior to cardiac transplantation. The patient was a 9-year-old boy in New York Heart Association functional class IV, with congestive heart failure as a result of idiopathic biventricular cardiomegaly. In mid-May of 1987, while awaiting a suitable donor, he suffered severe oliguria after an episode of circulatory arrest. Therefore we decided to maintain his circulation-and consequently his peripheral organ function-with an extracorporeal left ventricular assist device. After establishing cardiopulmonary bypass under normothermia and without cardiac arrest, we established flow from the left ventricle through a 36-Fr wire-reinforced straight cannula to a Biomedicus BP-80 centrifugal force pump, with return to the proximal ascending aorta through a 28-Fr wire-reinforced straight cannula. The patient's hemodynamic course under subsequent mechanical circulatory support was remarkably stable, with controllable systemic hypertension and no evidence of hemolysis. Although cardiac activity was minimal and systemic blood flow nonpulsatile, the patient's renal, pulmonary, and hepatic functions improved, and his peripheral circulation was well preserved. After 12 hours of support, a donor heart became available, and a routine orthotopic cardiac transplant was performed. Upon removal, the left ventricular assist device showed a small amount of thrombus formation. The patient's postoperative recovery has been easily manageable, and 20 months after transplant he enjoys unrestricted physical activity. We conclude that an extracorporeal left ventricular assist device can be used as a bridge to cardiac transplantation in children. Moreover, this application of a continuous force centrifugal pump without adverse effect encourages the conclusion that long-term maintenance of terminal heart disease patients might be possible through development of small, implantable pumps with the potential of lower power requirements and reduced thrombogenesis.