Pre-Operative Planning to Mitigate Risk in Complex Single Ventricular Assist Devices

Abstract

<h3>Introduction</h3> Infants with single ventricle (SV) anatomy are a high-risk group for ventricular assist device (VAD) support. Hybrid stage 1 palliation can be utilized to successfully bridge SV patients to transplantation, such as in the setting of atrioventricular valve regurgitation (AVVR) which precludes long-term SV palliation. Our case highlights how comprehensive pre-procedural planning can mitigate future risk of VAD implantation. <h3>Case Report</h3> A neonate with unbalanced right-dominant atrioventricular canal presented with severe AVVR and acute kidney injury (AKI) precluding traditional SV palliation. She underwent hybrid palliation as bridge to transplant. A 6 mm expandable PTFE graft was anastomosed to the pulmonary artery (PA); ductal stenting was performed through the graft which was then left <i>in situ</i>. She stabilized following initial palliation, but after 10 weeks developed progressive ventricular dysfunction and AKI (Figure 1). A PediMag continuous flow VAD was inserted off bypass using the previous graft for arterial outflow and a right atrial inflow cannula (Figure 2). Renal function recovered and the patient is awaiting transplant with stable hemodynamics. <h3>Summary</h3> Anastomosing a graft to the PA during hybrid palliation enabled placement of VAD off bypass in an infant with SV anatomy and AKI. Detailed pre-operative planning at the time of stage 1 palliation in high-risk infants with potential future VAD support needs may be beneficial as part of a strategy to avoid an early VAD when systemic output is adequate while decreasing subsequent operative risk at time of VAD insertion.