title: 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.
authors.affiliation: Department of Pediatric Cardiology, University of Texas Southwestern Medical Center and Children's Medical Center Dallas, TX 75235, USA. tracey.mackling@childrens.com
authors.forename: Tracey
authors.initials: T
authors.lastname: Mackling
authors.forename: Tejas
authors.initials: T
authors.lastname: Shah
authors.forename: Vivian
authors.initials: V
authors.lastname: Dimas
authors.forename: Kristine
authors.initials: K
authors.lastname: Guleserian
authors.forename: Mahesh
authors.initials: M
authors.lastname: Sharma
authors.forename: Joseph
authors.initials: J
authors.lastname: Forbess
authors.forename: Monica
authors.initials: M
authors.lastname: Ardura
authors.forename: Jami
authors.initials: J
authors.lastname: Gross-Toalson
authors.forename: Ying
authors.initials: Y
authors.lastname: Lee
authors.forename: Janna
authors.initials: J
authors.lastname: Journeycake
authors.forename: Aliessa
authors.initials: A
authors.lastname: Barnes
mesh_terms: D000925:Anticoagulants / Q000627:therapeutic use; D001604:Berlin; D002675:Child, Preschool; D015199:Extracorporeal Membrane Oxygenation / Q000009:adverse effects; D005260:Female; D018729:Fontan Procedure; D006333:Heart Failure / Q000150:complications / Q000209:etiology / Q000601:surgery*; D006353:Heart-Assist Devices; D006801:Humans; D018636:Hypoplastic Left Heart Syndrome / Q000601:surgery*; D008297:Male; D055624:Methicillin-Resistant Staphylococcus aureus / Q000302:isolation & purification; D009102:Multiple Organ Failure / Q000209:etiology; D011183:Postoperative Complications / Q000175:diagnosis* / Q000382:microbiology / Q000628:therapy; D051437:Renal Insufficiency / Q000628:therapy; D013203:Staphylococcal Infections / Q000175:diagnosis / Q000628:therapy
chemical_list: D000925:Anticoagulants