Device Implantation in a 26 kg Child

This article is part of CTSNet’s Guest Editor Series, Insights Into Pediatric Mechanical Circulatory Support. Congenital and pediatric surgeon Dr. Sandeep Sainathan invited accomplished pediatric surgeons from around the world to contribute clinical videos on the surgical aspects of pediatric mechanical circulatory support as a bridge to cardiac transplantation or recovery of cardiac function.   

The patient was a 26 kg child with a BMI of 17.9, diagnosed with hypoplastic left heart syndrome who underwent single ventricle palliation to a Fontan. The patient experienced single ventricle failure due to a micro aortic thrombus, resulting in failing Fontan symptoms. 

Preoperative virtual modeling was done to confirm the fit of the left ventricular assist device (LVAD) in this diminutive patient with a body surface areas of 0.83m². 

A redo median sternotomy was performed, followed by dissection of the adhesions. The site for the VAD inflow cannula was marked at the right ventricular apex near the acute margin. The outflow graft distance to the ascending aorta was measured from the diaphragm. 

An end-to-side anastomosis of the outflow graft to the aorta was planned. An aortotomy was performed on the right lateral aspect of the ascending aorta above the sinotubular junction, and the angles of the incision were enlarged using a punch. 

Careful deairing of the graft was performed. Circumferential sutures were placed to anchor the mini apical sewing ring of the inflow cannula to the right ventricular apex. The skin was incised in the right upper quadrant for the exit site of the driveline. Care was taken not to excessively handle the incision to avoid postoperative driveline infections. A tunneling tool was used to deliver the driveline out of the mediastinum and through the exit site at the skin. 

The patient was then converted from neck extracorporeal membrane oxygenation (ECMO) to full cardiopulmonary bypass. The right ventricular apex was incised, and all the muscular attachments that were crowding the orifice were divided. The coring tool was not used, as there was uncertainty regarding the attachments of the tricuspid valve to the free wall. Circumferential sutures were placed through the mini-apical sewing ring and tied into position. 

It was noted that there was muscle impingement into the right ventricular apex after the sutures were tied down. Consequently, the coring tool was used to further enlarge the inflow orifice. 

The LVAD was then deaired and brought into the field. The device was lowered into the right ventricular apex through the mini-apical sewing ring and locked into position using the cuff lock. Care was taken to ensure that the cuff lock was completely deployed. The bend relief outflow graft was screwed onto the pump until a confirmatory click was heard. 

The LVAD was then lowered into the left chest. The outflow graft was deaired with a needle, and the device started at 3000 rpm as the clamp on the outflow graft was gradually removed. These were the postoperative device settings and hemodynamics of the patient. 

The postoperative chest X-ray showed the final position of the device, which was somewhat impacted by the narrow chest dimensions. This patient is currently listed for a heart transplant and awaiting an organ. 

References

1. Deng MX, Yoshida N, Haller C, Jeewa A, Yoo SJ, Honjo O. Durable left ventricular assist devices in pediatrics: impact of body size on outcomes and size limitations. J Artif Organs. 2024 Sep 6. doi: 10.1007/s10047-024-01467-7. Epub ahead of print. PMID: 39240401.

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