Berlin Heart Explantation Systematic Approach Protocol in a Single Center Experience

Abstract

Introduction Berlin Heart EXCOR ventricular assist device (VAD) implantation in children is widely used as a bridge-to-heart transplantation. VAD support as a bridge-to-recovery is rare. There is scarcity of literature describing systematic evaluation of cardiac recovery employed in VAD explanation in children. Case Report A 13 month-old boy presented to the emergency department with acute congestive heart failure secondary to myocarditis. Echocardiogram demonstrated severely depressed left ventricular (LV) function with severe mitral regurgitation. He developed ventricular tachycardia with hemodynamic compromise necessitating institution of veno-arterial extracorporeal membranous oxygenation (ECMO). He was decannulated 11 days later after a successful trial off, but due to no further improvement in cardiac status, he underwent Berlin Heart EXCOR LVAD placement as a bridge-to-transplant. After 3 months of VAD support, we noted evidence of myocardial recovery and discussed the possibility of VAD explant. A weaning protocol was developed that consisted of two phases. The first phase consisted of a trial off with echocardiographic monitoring of biventricular function, atrioventricular valve regurgitation and LV diastolic dimension. The second phase was performed one week later in the cardiac catheterization suite, while monitoring hemodynamic measurements at baseline and with manual pumping followed by dobutamine challenge at the end of trial off. Clinical data was satisfactory and patient met established goals to undergo explant. Berlin explantation was succesfully performed the following day. His recovery was unremarkable and was discharged 2 weeks after explant. Patient was seen for follow-up at 1, 2 and 3 months post-discharge and he is doing well. Summary We established guidelines for trialing off VAD support to maximize the identification of potential candidates for VAD explantation. This protocol includes three main stages: screening, trial-off with echocardiography and trial-off in the catheterization suite. This case demonstrates that myocardial recovery can take longer than previously recognized in children with myocarditis and it highlights that strong consideration should be given to patients with a stable VAD course to remain inactive on the heart transplant waitlist to allow time for myocardial recovery and successful explantation.