Atrial Cannulation Research Articles

An association between early rescue left heart unloading during VA-ECMO treatment and prognosis of cardiogenic shock; the post-hoc study of the EARLY-UNLOAD trial

Abstract Funding Acknowledgements None. Background/introduction Recently published studies showed prophylactic left heart unloading does not improve mortality in cardiogenic shock (CS) treated with venoatrial extracorporeal membrane oxygenation (VA-ECMO). However, significant proportion of patients on VA-ECMO treatment for CS require early rescue left heart unloading. Purpose To compare characteristics and prognosis according to rescue-unloading timing in patients with CS treated with VA-ECMO. Methods This study is a post-hoc analysis of the EARLY-UNLOAD trial (NCT04775472), the trial evaluated an impact of an early prophylactic unloading strategy using left atrial cannulation (LAC) within 12 hours from the initiation of VA-ECMO treatment. This analysis was performed per-protocol basis for patients without violation (N = 108). Patients were classified into four groups according to timing of left heart unloading: prophylactic (<12h, N = 53), early rescue (<30h, N = 16), late rescue (>30h, N= 10), and no unloading (N = 29). The primary endpoint was in-hospital mortality, and secondary endpoint was 30-day all-cause death. Logistic regression was used to search factors related to the primary endpoint. Results Among patients in the conservative strategy arm, rescue unloading was performed in 47% of patients, and 29% of patients received left heart unloading within 30 hours. Median time from ECMO pump on to rescue unloading was 23 hours. Compared to other groups, the early rescue group had the highest initial arterial lactate level (6.2 vs 11.4 vs 4.3 vs 6.3 mmol/L, prophylactic, early rescue, late rescue, and no unloading, respectively, P = 0.011) and SAPS2 score at baseline (52.7 vs 68.2 vs 50.6 vs 55.7, P = 0.017). Inotropes requirement on day 1 was also highest in the group (vasoactive-inotropic score, 12.4 vs 31.2 vs 7.5 vs 13.8, P = 0.014). The early rescue unloading group showed the highest in-hospital mortality (Figure 1, 87.5%, P = 0.004) and 30-day mortality (75%, P = 0.029). Survival analysis using Kaplan-Meier analysis and log-rank test showed significant difference of probability of all cause death at 30 days among these 4 groups (Figure 2, P by log-rank test = 0.049). In the logistic regression models for in-hospital mortality, rescue unloading within 30 hours was associated with increased odds ratio (OR) for in-hospital mortality (OR = 6.87, 95% confidence interval [CI] = 1.31-35.92.15, P = 0.022). Conclusions In this post-hoc analysis of the EARLY-UNLOAD trial, early-rescue unloading within 30 hours was associated with increased in-hospital mortality in patient treated with VA-ECMO for CS.

Impact of early administration of beta-blocker and RAS inhibitor during VA-ECMO treatment for cardiogenic shock; the post-hoc study of the EARLY-UNLOAD trial

Abstract Funding Acknowledgements None. Background/introduction No data about timing and impact of beta-blocker (BB) or renin-angiotensin-aldosterone system inhibitor (RASi) administration for cardiogenic shock (CS) treated with venoatrial extracorporeal membrane oxygenation (VA-ECMO). Purpose To analyze an impact of early administration of BB or RASi during VA-ECMO treatment. Methods This study is a post-hoc analysis of the EARLY-UNLOAD trial (NCT04775472), the trial evaluated an impact of an early prophylactic unloading strategy using left atrial cannulation (LAC) performed within 12 hours from the initiation of VA-ECMO treatment for CS. Among total population (N=116), patients whose lactate was normalized during VA-ECMO and survived more than 2 days were included in this analysis (N=103). Patients were classified whether each medication (BB, RASi or one of BB or RASi) was administered during VA-ECMO or not. The primary endpoint was all-cause mortality. Survival analysis for a primary outcome and landmark analysis for all-cause mortality during different periods (<10 days, 10 to 30 days) were performed. Results BB, RASi, and BB or RASi were administered in 71.8%, 72.8%, and 83.5% of patients, respectively, during VA-ECMO treatment. In early treatment groups, Both BB and RASi were initiated on day 1 (as median). Duration of VA-ECMO treatment was longer in a group who treated with BB during VA-ECMO (8.5 days, vs 5.0 days as median, P = 0.003), and for RASi, it was comparable (8.0 days vs 7.0 days, P = 0.609). Incidence of 30-day all-cause mortality at were statistically comparable between groups (figure 1). The results of survival analysis are described in the figure 2. In Kaplan-Meier analysis, BB, RASi, and BB or RASi during VA-ECMO treatment was not associated with lower probability of 30-day all-cause mortality. Landmark analysis, however, showed lower probability of 10-day mortality in the group treated with BB (P by log-rank test = 0.045), RASi (P = 0.008) and BB or RASi (P=0.005) during VA-ECMO. Multivariate Cox proportional modellings also provided lower risk of 10-day all-cause mortality in groups with BB treatment (Hazard ratio [HR] = 0.26, 95% confidence interval [CI]=0.10-0.69, P = 0.007), RASi treatment (HR = 0.22, 95% CI = 0.08-0.56, P = 0.001) or BB or RASi (HR = 0.15, 95% CI = 0.05-0.41, P < 0.001) during VA-ECMO. RASi (HR = 0.47, 95% CI = 0.22-0.97, P = 0.041) or BB or RASi (HR = 0.37, 95% CI = 0.15-0.93, P = 0.038) treatment during VA-ECMO was also associated with lower risk of 30-day all-cause mortality. Conclusions In this post-hoc analysis of the EARLY-UNLOAD trial, administration of BB or RASi during VA-ECMO treatment for CS was associated with lower risk of short-term mortality.

Balloon atrial septostomy versus left atrial cannulation for left heart decompression in children with dilated cardiomyopathy and myocarditis on extracorporeal membrane oxygenation: An ELSO registry analysis.

In children with myocarditis or dilated cardiomyopathy (DCM) on extracorporeal membrane oxygenation (ECMO) for cardiogenic shock, it is often necessary to decompress the left heart to minimize distension and promote myocardial recovery. We compare outcomes in those who underwent balloon atrial septostomy (BAS) versus direct left atrial (LA) drainage for left heart decompression in this population. Retrospective study of the Extracorporeal Life Support Organization (ELSO) multicenter registry of patients ≤ 18years with myocarditis or DCM on ECMO who underwent LA decompression. Descriptive and univariate statistics assessed association of patient factors with decompression type. Multivariable logistic regression sought independent associations with outcomes. 369 pediatric ECMO runs were identified. 52% myocarditis, 48% DCM, overall survival 74%. 65% underwent BAS and 35% LA drainage. Patient demographics including age, weight, gender, race/ethnicity, diagnosis, pre-ECMO pH, mean airway pressure, and arrest status were similar. 89% in the BAS group were peripherally cannulated onto ECMO, versus 3% in the LA drainage group (p < .001). On multivariable analysis, LA drainage (OR 3.96; 95% CI, 1.47-10.711; p = .007), renal complication (OR 2.37; 95% CI, 1.41-4.01; p = .001), cardiac complication (OR 3.14; 95% CI, 1.70-5.82; p < .001), and non-white race/ethnicity (OR 1.75; 95% CI, 1.04-2.94; p = .035) were associated with greater odds of mortality. There was a trend toward more episodes of pulmonary hemorrhage in BAS (n = 17) versus LA drainage group (n = 3), p = .08. Comparing only those with central cannulation, LA drainage group was more likely to be discontinued from ECMO due to recovery (72%) versus the BAS group (48%), p = .032. In children with myocarditis or DCM, there was a three times greater likelihood for mortality with LA drainage versus BAS for LA decompression. When adjusted for central cannulation groups only, there was better recovery in the LA drainage group and no difference in mortality. Further prospective evaluation is warranted.

Rescuing the Right Ventricle: Mechanical Support After Pediatric Heart Transplantation

BackgroundRight ventricular (RV) failure after heart transplantation (HT) is common in those with pretransplantation elevated pulmonary vascular resistance (PVR). Mechanical circulatory support has been used as a bridge to recovery, with mixed outcomes. We describe a patient with failed single-ventricle palliation in whom severe RV failure developed after HT. We review the current literature and outline our post-HT strategy. MethodsAn infant with trisomy 21, severely unbalanced right dominant atrioventricular septal defect, and hypoplastic aortic arch was palliated with a hybrid procedure. At 6 months of age, cardiac catheterization measured PVR index of 5.47 Wood units × m2 on maximal medical therapy. The patient was deemed unsuitable for second-stage palliation and underwent HT at 18 months of age. Despite preemptive medical therapies, acute RV failure developed, necessitating extracorporeal membrane oxygenation. He was quickly converted to main pulmonary artery to left atrial cannulation. Unloaded RV function normalized; he was weaned from support and discharged home 5 weeks after HT. ResultsFailure of medical therapy in RV failure after HT requires escalation to mechanical circulatory support. We review the literature on RV failure and support after HT. We also describe a novel cannulation strategy to provide a reliable way to directly reduce RV afterload, to allow physiologic training of the right ventricle to a higher PVR, and to maintain normal left ventricular coupling and loading. ConclusionsIn pediatric patients with elevated PVR undergoing HT, advanced therapies can be used effectively to treat acute RV failure. Unique cannulation strategies may play a role in improving survival of similar patients.

PEDS7: Balloon Atrial Septostomy versus Left Atrial Cannulation for Left Heart Decompression in Children with Dilated Cardiomyopathy and Myocarditis on Extracorporeal Membrane Oxygenation

Purpose: To describe the association of left heart decompression with balloon atrial septostomy (BAS) compared to left atrial (LA) cannulation with survival in children with myocarditis or dilated cardiomyopathy (DCM) on veno-arterial extracorporeal membrane oxygenation (ECMO). Methods: Retrospective study of the Extracorporeal Life Support Organization (ELSO) multicenter registry of patients ≤ to 18 years old with myocarditis or DCM on ECMO who underwent LA decompression. Only index ECMO run within a hospitalization was included. Descriptive and univariate statistics assessed association of patient factors with decompression type. Multivariable logistic regression sought independent associations with outcomes. Results: 321 pediatric ECMO runs were identified. 57% myocarditis (n=183) and 43% DCM (n=138). Survival overall was 74%. 67% underwent balloon atrial septostomy (BAS) and 33% underwent left atrial cannulation. Patient demographics including age, weight, gender, race/ethnicity, diagnosis, pre-ECMO pH, mean airway pressure, and arrest status were similar between groups. Median ECMO duration was longer in the BAS group compared to LA cannulation (7.2 versus 5.7 days respectively, p=0.002). 82 (78%) were centrally versus peripherally (22%, n=23) cannulated on ECMO in the LA cannulation group, versus 19 (9%) centrally versus 194 (91%) peripherally cannulated in the BAS group. On multivariable analysis, we found LA cannulation (OR 3.68; 95% CI, 1.86-7.31; p<0.001), neurologic complication (OR 5.25; 95% CI, 2.38-11.58; p<0.001), renal complication (OR 2.74; 95% CI, 1.41-5.29; p=0.003), and cardiac complication (OR 2.64; 95% CI, 1.30-5.38; p=0.007) were associated with greater odds of mortality. There were more episodes of pulmonary hemorrhage in the BAS group (n=17) compared to the LA cannulation group (n=2). Conclusions: Our findings indicate better left heart decompression with an LA cannula compared to BAS given a lower incidence of pulmonary hemorrhage in the LA cannulation group. There was a three times greater likelihood for mortality in children with myocarditis and DCM on ECMO who undergo LA cannulation compared to BAS, however, they appear to be fundamentally different cohorts. Further prospective evaluation with adjustment for severity of illness is warranted.

Diagnostic Accuracy of the 2016 Guideline-Based Echocardiographic Algorithm to Estimate Invasively-Measured Left Atrial Pressure by Direct Atrial Cannulation

BackgroundAlthough estimation of left ventricular filling pressure (LVFP) using an integrated echocardiographic algorithm is recommended, the usefulness of this algorithm has not been fully validated. ObjectivesThe purpose of this study was to investigate the reliability of an algorithmic classification system using invasively measured left atrial pressure (LAP) in a large-scale cohort. MethodsThe authors enrolled 1,967 patients (age 68 ± 10 years) whose LAP was directly measured within the left atrium during catheter ablation for atrial fibrillation. Patients were classified into 3 groups based on the echocardiographic algorithm: normal (group N, n = 1,282), undetermined (group U, n = 160), and elevated (group E, n = 346) LAP groups. Invasively measured LAP and echocardiographic parameters estimating LVFP were compared among the groups. ResultsThe median LAP was 12.6 ± 5.7 mm Hg in the entire cohort. LAP was significantly higher in group E than that in the other groups (groups E vs U vs N, 14.2 ± 6.3 mm Hg vs 13.5 ± 5.9 mm Hg vs 12.0 ± 5.5 mm Hg; P < 0.001). Among group E patients, 43.1% had elevated LAP (≥15 mm Hg), whereas 56.9% had normal LAP (<15 mm Hg). Of the patients in group N, 69.0% had normal LAP, whereas 31% had elevated LAP. Although the correlation between invasively measured LAP and E/e′, peak tricuspid regurgitant velocity, and left atrial volume index was modest, the number of abnormal values correlated significantly with elevated LAP (P < 0.001). ConclusionsThe classification using combined echocardiographic parameters in the recommendations may be useful for detecting patients with normal LVFP but may be limited for detecting elevated LVFP.

Atrial Cannulation During Resuscitative Clamshell Thoracotomy.

Resuscitative thoracotomy and clamshell thoracotomy are performed in the setting of traumatic arrest with the intent of controlling hemorrhage, relieving tamponade, and providing open chest cardiopulmonary resuscitation. Historically, return of spontaneous circulation rates for penetrating traumatic arrest as well as out of hospital survival have been reported as low as 40% and 10%. Vascular access can be challenging in patients who have undergone a traumatic arrest and can be a limiting step to effective resuscitation. Atrial cannulation is a well-established surgical technique in cardiac surgery. Herein, we present a case series detailing our application of this technique in the context of acute trauma resuscitation during clamshell thoracotomy for traumatic arrest in the emergency department. A retrospective case series of atrial cannulation during traumatic arrest was conducted in Charlotte, NC at Carolinas Medical Center an urban level 1 trauma center. The mean rate of return of spontaneous circulation in our series, 60%, was greater than previously published upper limit of return of spontaneous circulation for penetrating causes of traumatic arrest. Intravenous access can be difficult to establish in the hypovolemic and exsanguinating patient. Traditional methods of vascular access may be insufficient in the setting of central vascular injury. Atrial appendage cannulation during atrial cannulation is a quick and reliable technique to achieve vascular access that employs common methods from cardiac surgery to improve resuscitation of traumatic arrest.

Thoracoabdominal Normothermic Regional Perfusion for Cardiac Procurement.

In donation after circulatory death donors, warm ischemia time is a significant threat to successful cardiac transplantation. The ability to perfuse these organs during the minutes after death, until cardiac evaluation is completed to satisfaction, is crucial in limiting total warm ischemic time. Thoracoabdominal normothermic regional perfusion (TANRP) has emerged as a promising strategy for recovering and monitoring these hearts. We propose a series of clinical practice pearls that we follow for all donation after circulatory death procurements to streamline the process of setting up a TANRP circuit and ensuring all team members present at time procurement are familiar with the procedure. Bicaval cannulation is achieved via the abdomen for aortic cannulation, and via the chest for right atrial cannulation, avoiding deairing maneuvers and providing the shortest possible duration from incision to initiation of cardiopulmonary bypass. Here, we describe a series of practice techniques which we have utilized in our early experience with TANRP.

Lung Transplantation in COVID-19 Induced End Stage Lung Disease

IntroductionIn a subset of patients COVID-19 induced lung injury progresses to irreversible lung damage and pulmonary fibrosis. Bilateral orthotopic lung transplant (BOLT) has been used as a rescue therapy in these patients. We describe four patients who were bridged to BOLT using venovenous extracorporeal membrane oxygenation (VV-ECMO).Case ReportBetween October 13, 2020 and February 14, 2021, four patients with SARS-CoV-2 infection underwent BOLT for end-stage pulmonary fibrosis demonstrated on computed tomography. Median age was 42 years and three were male. One patient had a prior history of undifferentiated interstitial lung disease managed with chronic steroids. Pre-transplant hospital course was complicated by right ventricular failure due to pulmonary hypertension in two patients and ventilator-associated pneumonia in one. One patient developed heparin-induced thrombocytopenia requiring anticoagulation with bivalirudin perioperatively. Three patients were non-ambulatory and bedridden for a median of 54 days prior to surgery. Timing of transplantation ranged from hospital day 26 - 68 with a median of 48 days. At the time of transplant, three patients were mechanically ventilated via tracheostomy, while all were on VV-ECMO a median of 27 (IQR 11 - 42) days. All patients underwent BOLT via clamshell exposure utilizing cardiopulmonary bypass (CPB) with aortic and right atrial cannulation. VV-ECMO was discontinued intraoperatively in all cases after initiating CPB. All patients required intraoperative blood transfusion with a median of 3 units. The three patients with tracheostomy prior to transplant were liberated from the ventilator a median of 9 days postoperatively and decannulated from their tracheostomy a median of 11 days postoperatively. Aside from one patient requiring short courses of hemodialysis, there were no significant postoperative complications. Patients were discharged a median of 17 (14 - 20) days following surgery. After a median follow-up of 226.5 (223 - 257.75) days, all four patients were alive with no supplemental oxygen requirement.SummaryPulmonary fibrosis secondary to COVID-19 pneumonia can be successfully treated with VV-ECMO and subsequent lung transplantation in select patients. Special consideration should be given to this patient population as they may not meet traditional listing requirements. We report a 100% oxygen-free survival rate at six months.

Novel Left Atrial Cannulation Technique for Attachment of a Pumpless Artificial Lung.

A pumpless artificial lung has the potential to provide a bridge to recovery or transplantation in children with respiratory failure. Pulmonary artery inflow and left atrial outflow are necessary for low-gradient, pumpless systems; however, long-term cannulation of the fragile left atrium remains problematic. In this technique, the left atrium and pulmonary artery were exposed through a left anterior thoracotomy. Inflow to the artificial lung was created using an end-to-side anastomosis with the pulmonary artery. Device outflow was established through the left atrium. A single-stage venous cannula was passed through a free PTFE graft. Using polypropylene with pledgets, two concentric purse-string sutures were placed in the dome of the left atrium. The venous cannula was inserted. The graft was slid down the cannula and circumferentially secured to the adjacent left atrial tissue and pledgets. The other end of the graft was secured to the cannula with silk ties. The procedure was successful in 10 sheep. Initial device blood flow was 969 ± 222 ml/min, which remained stable for up to 7 days with no anastomotic complications. This is an effective method of achieving secure, long-term left atrial cannulation without cardiopulmonary bypass for use in a low-resistance, pumpless artificial lung. And, most importantly, improves the ease and safety of cannula replacement and final decannulation when AL support is no longer required.

A Multi-Domain Simulation Study of a Pulsatile-Flow Pump Device for Heart Failure With Preserved Ejection Fraction.

Mechanical circulatory support (MCS) devices are currently under development to improve the physiology and hemodynamics of patients with heart failure with preserved ejection fraction (HFpEF). Most of these devices, however, are designed to provide continuous-flow support. While it has been shown that pulsatile support may overcome some of the complications hindering the clinical translation of these devices for other heart failure phenotypes, the effects that it may have on the HFpEF physiology are still unknown. Here, we present a multi-domain simulation study of a pulsatile pump device with left atrial cannulation for HFpEF that aims to alleviate left atrial pressure, commonly elevated in HFpEF. We leverage lumped-parameter modeling to optimize the design of the pulsatile pump, computational fluid dynamic simulations to characterize hydraulic and hemolytic performance, and finite element modeling on the Living Heart Model to evaluate effects on arterial, left atrial, and left ventricular hemodynamics and biomechanics. The findings reported in this study suggest that pulsatile-flow support can successfully reduce pressures and associated wall stresses in the left heart, while yielding more physiologic arterial hemodynamics compared to continuous-flow support. This work therefore supports further development and evaluation of pulsatile support MCS devices for HFpEF.

Durable mechanical circulatory support in patients with heart failure with preserved ejection fraction.

Only few patients with heart failure with preserved ejection fraction undergo durable mechanical circulatory support implantation. We identified three patients with heart failure with preserved ejection fraction who needed durable mechanical circulatory support as bridge-to-transplant therapy. In two patients with hypertrophic cardiomyopathy, the hypertrophic papillary muscles and myocardium were resected to allow for subsequent left ventricular assist device implantation. In one patient, all visible parts of the mitral valve were additionally resected. The third patient with restrictive cardiomyopathy underwent Berlin Heart Excor BVAD implantation with left atrial cannulation.

Minimal Invasive Aortic Valve Replacement Through Right Mini_Thoracotomy Versus Conventional Approach In The Egypt

Background: Full median sternotomy was established a long time ago as the standard approach for all varieties of heart surgery. Although that, it may cause significant surgical trauma and morbidity, so minimally invasive cardiac surgery for aortic valve replacement via partial sternotomy, para-sternal approach and anterior mini-thoracotomy is used trying to improve the outcome . Objective: to check the outcome of minimally invasive aortic valve surgery through a right mini-thoracotomy, and its rule in minimizing the surgical access, achieving better wound appearance, decreasing post-operative discomfort and better postoperative recovery with the same safety and results like conventional surgery . Methods: our study was performed in the Armed Forces Hospitals El Maddi& El Galaa and kobry elkobba, Egypt. Between January 2015 to March 2017, sixty patients were diagnosed with AVD requiring aortic valve surgery were randomly selected, of them Thirty patients had aortic valve surgery through full median sternotomy with aorto-right atrial cannulation and the other thirty patients had right mini-thoracotomy with femoral cannulation . Results# Minimally invasive aortic valve replacement (MIAVR) was associated with reduced morbidity and mortality, where there was a safer approach in case of re-operation, better cosmetic outcome, less bleeding post-operative, lower number of blood products usage, less intensive care unit and hospital stays, decreased time until return to full activity and avoiding the incidence of sternal wound infection. That good results were also achievable in high-risk patients . Conclusion: Minimal Invasive Aortic Valve Replacement Through Right Mini-thoracotomy is an acceptable alternative to Full median sternotomy, has reduced morbidity and potential mortality and good clinical outcome, with two concerns which are the operative cost and the relatively long bypass and cross clamp time which are related to the learning curve of the surgeons

Atrial Cannulation in Pediatric Mechanical Circulatory Support

Purpose Several centers have considered the potential benefits of atrial inflow cannulation to provide mechanical circulatory support (MCS) among pediatric patients with small or restrictive ventricles particularly in those with potential for myocardial recovery. Limited pediatric data are available on contemporary outcomes of atrial cannulation. We sought to describe the characteristics, complications, and outcomes of children supported with atrial cannulation using the Advanced Cardiac Therapies Improving Outcomes Network (ACTION) ventricular assist device (VAD) database. Methods Data were collected from the ACTION VAD database for all patients who underwent VAD implantation via atrial cannulation from 8/16/2012 to 9/8/2020. Patient characteristics, VAD types, complications, and outcomes were analyzed. Results Forty-one patients met the study criteria with 52 implants. Median age was 3.6 years (range 0.02 - 25.32), weight 13.6 kg (2.7-106), and BSA 0.6 (0.15 - 2.2). Diagnoses included dilated cardiomyopathy (42%), congenital heart disease (37%), transplant graft dysfunction (7%), restrictive and hypertrophic cardiomyopathies (5% each). VAD indications were bridge to decision (42%), bridge to transplant (42%), and bridge to recovery (17%). Eighty-four percent of patients were INTERMACS 1 or 2, 44% were on ECMO, and 63% were mechanically ventilated. Devices utilized included Berlin Heart Excor (40%), paracorporeal continuous flow devices (38%), Heartware (19%) and one Heartmate 3. Median support duration was 43.5 days (range 0-307). Overall mortality was 22%. Twenty patients (49%) were successfully transplanted, 7 (17%) recovered, and 5 (12%) are still alive on the device. Adverse events included major bleeding (24%), stroke (12%), sepsis (10%), right heart failure requiring RVAD (5%), and one instance of pump thrombosis. Conclusion Atrial cannulation in pediatric MCS can be performed across a variety of anatomic substrates and age ranges with outcomes and complication rates that are comparable to left ventricular cannulation strategies. This method may be advantageous in certain circumstances including patients with small or restrictive ventricles, potential for myocardial recovery, or multiple prior sternotomies to minimize surgical dissection. Further studies are needed to delineate the ideal patient population and benefits of varying atrial cannulation techniques.

Biventricular Assist Device Support of a Child with Intractable Arrhythmias Secondary to Histiocytoid Cardiomyopathy

Introduction Histiocytoid cardiomyopathy (HICMP) is a rare mitochondrial cardiomyopathy associated with intractable, life-threatening ventricular arrhythmias. Dilated, hypertrophic, and noncompaction phenotypes can also be seen with HICMP and have the potential to progress to heart failure. Heart transplantation (HT) and left ventricular assist device (VAD) support for heart failure in HICMP have been described in case reports, but there has been no published experience on Biventricular VAD (BiVAD) support for intractable arrhythmias in HICMP. Case Report A 13-month-old presented with lethargy, poor perfusion, and ventricular tachycardia (VT) with wide- and narrow-complex morphology. Ejection fraction was 54% with left ventricular (LV) noncompaction. Electrical and chemical rhythm control were unsuccessful, and rate control was complicated by symptomatic bradycardia. Rhythm control was transiently achieved with percutaneous stellate ganglion block, but the frequency of breakthrough ventricular fibrillation (VF) subsequently increased. PediMag® BiVAD with LV apical cannulation was implanted as a bridge to transplantation (BTT), with eventual conversion to Berlin Heart EXCOR® BiVAD. HICMP was confirmed by pathology at time of implant. Post-operative course was complicated by suction events, likely secondary to cannula position and underlying rhythm, as suction only occurred during systole in sinus rhythm. Suction events resolved with revision to left atrial cannulation. She continued to alternate between sinus rhythm, VF, VT, and asystole and intermittent “pauses” (no fill/no eject) were observed during sinus rhythm, likely due to competition from intrinsic ejection. She is now 4 months into BiVAD support with alternating sinus, VT, and VF rhythms, no device related complications, and excellent rehabilitation as she awaits HT. Summary We report our experience with BiVAD support of a 13-month-old with HICMP and intractable arrhythmias as BTT. In small children, it is important to understand the potential impact of cannula position and heart rhythm on device performance. Even in the absence of ventricular dysfunction, BiVAD support with atrial cannulation can provide excellent hemodynamic support for patients with HICMP and life-threatening arrhythmias.

Pre-Mortem Percutaneous Femoral Venous Cannulation Significantly Reduces Blood Collection Time and Warm Ischemic Time in Donation after Circulatory Death Heart Procurement

<h3>Purpose</h3> Successful collection of donor blood in donation after circulatory death (DCD) heart procurement when utilizing the TransMedics organ care system (OCS) is essential. This must be done expeditiously in order to minimize donor organ warm ischemic time as no flush can begin until the donor blood has been collected. This study investigated pre-mortem percutaneous femoral venous cannulation (PFVC) compared to post-mortem right atrial cannulation (RAC) to determine if there would be a reduction in time needed to collect donor blood as well as time to heart flush. <h3>Methods</h3> We compared time taken to collect 1,800 mL of donor blood and time to heart flush using post-mortem RAC and pre-mortem PFVC in DCD donors. With the RAC technique, the chest was entered expeditiously after the donor progressed and the right atrium was cannulated for donor blood collection. The PFVC technique utilized a femoral venous cannula placed percutaneously pre-mortem and clamped after the donor was systemically heparinized. Once the donor had progressed and procurement was allowed to begin, the cannula was unclamped and blood collection began immediately. The times from incision to completion of blood collection and to heart flush were recorded. <h3>Results</h3> A total of 8 donors were included in the study. Four donors were assigned to the RAC technique and 4 to the PFVC technique. The two groups were comparable based on age, gender and BMI. They also had similar values of hematocrit. Time to blood collection and time to heart flush were significantly decreased by approximately 110 seconds each in the femoral cannulation group (Table 1). <h3>Conclusion</h3> Our preliminary data shows that utilization of PFVC in DCD heart procurement significantly reduced time needed to collect the blood volume required as well as reduction in time to heart flush (warm ischemic time). This technique also allowed for immediate decompression of the heart and made prompt entry into the chest easier and safer.

Comparative study between aortic valve replacement through full sternotomy versus mini-sternotomy

Background: The superiority of minimally invasive aortic valve replacement (AVR) over the standard approach is the subject of ongoing research. The aim of this study was to compare the outcomes of AVR through full sternotomy versus mini-sternotomy.&#x0D; Methods: We included 60 patients who had AVR; 30 patients underwent AVR through J- or T-shaped mini-sternotomy, and 30 patients had a full sternotomy. We included patients who had isolated AVR and excluded patients who had a concomitant cardiac procedure, redo surgery, or those who needed annular dilatation. All patients had aortic and right atrial cannulation for cardiopulmonary bypass. Study endpoints were operative times, postoperative complications and duration of ICU and hospital stays.&#x0D; Results: There were no differences between the two groups preoperatively. Cardiopulmonary bypass time was longer in the mini-sternotomy group (median: 100 (range: 65- 170) vs. 85 (55-160) min, respectively; p= 0.024). Operative time was non-significantly longer in the mini-sternotomy group 5 (4-6) hours vs. 4.5 (4-6) hours in the full sternotomy group (p=0.62). Ventilation time was 10 (4- 50) hours in the mini-sternotomy group vs. 14 (8- 45) hours in the full sternotomy group (p&lt;0.001). ICU stay was shorter in the mini-sternotomy group (2 (1-6.5) vs. 2.5 (1-7) days, respectively, p= 0.014). The total mediastinal drainage was 100 (50 400) ml in the mini-sternotomy group vs. 275 (50- 1000) ml in the full sternotomy group (p= &lt;0.001). There was no difference in wound infection (p= 0.35), tamponade (p˃0.99), and hemothorax (p˃0.99) between both groups.&#x0D; Conclusion: Mini-sternotomy AVR had longer cardiopulmonary bypass times; however, there were no differences in the postoperative complications compared to the full sternotomy approach. Mini-sternotomy could be a safe alternative approach to the full median sternotomy for aortic valve replacement.

H-repair in supravalvular aortic stenosis.

H-repair in supravalvular aortic stenosis.

Pulsatile ventricular assist device as a bridge to transplant for the early high-risk single-ventricle physiology

BackgroundThe use of ventricular assist devices (VADs) as a bridge-to-transplant in patients with single-ventricle physiology post–stage one palliation has been associated with poor outcomes. We describe our center's successful experience in the use of paracorporeal pulsatile VADs in the palliation of high-risk single ventricle physiology before or after the first stage of palliation with an impetus on pre-palliation implant. MethodsThis is a single-center retrospective review of univentricular patients implanted with the Berlin Heart EXCOR VAD. Our center's approach includes early implantation of the Berlin Heart EXCOR with common atrial cannulation, a cardiac index between 3.5 and 5 L/min/m2, and a bivalirudin-based anticoagulation regimen. Patient-related data were collected postimplant at week 1 and months 1, 2, and 3. Post-transplant data, including neurological outcomes, were collected. ResultsNine patients were supported. Survival to discharge post-transplant was 83% (5/6) in patients bridged-to-transplant and 33% (1/3) in patients bridged-to-decision. Six patients had no previous palliation. Median hospital stay before implantation was 111 days for nonsurvivors versus 20 days for survivors. The need for extracorporeal membrane oxygenation and cardiopulmonary resuscitation in nonsurvivors versus survivors was 1 in 3 versus 1 in 6 and 2 in 3 versus 1 in 6, respectively. There were no major central nervous system complications except for 1 significant hemorrhagic event. The pediatric overall performance category score on follow-up was normal to mild disability in 83% of survivors. Limitations include hemolysis and intermittent periods of infection and/or inflammation. ConclusionsThe use of pulsatile paracorporeal VADs is a feasible option as a bridge-to-transplant in the peri–stage one high-risk single ventricle.

Mechanical Support of the Failing Fontan Circulation

The Fontan is the final common pathway for most single ventricle lesions. It is not a durable circulation and many Fontan patients eventually present for advanced heart failure therapies including mechanical circulatory support. While there have been advancements in available durable devices, many pediatric patients have size, anatomical, and physiologic constraints that make placement of adult ventricular assist devices challenging. And, Fontan failure comes in different varieties, including failure with preserved systolic function. This subset of patients requires either a subpulmonary assist device or a total artificial heart. Unique operative maneuvers, including atrial cannulation and atrioventricular valve manipulation have allowed many failing Fontan patients to be bridged to transplant after recovery of end-organ dysfunction and improved nutrition. The Advanced Cardiac Therapies Improving Outcomes Network is a multicenter learning network of pediatric hospitals implanting, managing, and studying ventricular assist devices in children and adults with congenital heart disease. This network is advancing the knowledge of outcomes and approaches to mechanical circulatory support in those with congenital heart disease, including Fontans. The congenital heart disease community continues to work toward and hope for a smaller durable device that will help this complex cohort of patients.