Ventricular Assist Device (VAD) Implantation at Great Ormond Street Hospital: A Decade of Experience

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.    

Great Ormond Street Hospital (GOSH) in London is world -renowned for its expertise in managing end-stage heart failure. Between 2014 and 2024, 173 ventricular assist devices (VADs) were implanted at GOSH, achieving excellent outcomes through meticulous surgical techniques and multidisciplinary care. 

Device and Team Approach 

At GOSH, a pediatric VAD is utilized. This mechanical, pulsatile device is available in different sizes to accommodate children from newborns to adolescents. A dedicated VAD team collaborates closely with the manufacturer to ensure optimal perioperative and postoperative care. 

Surgical Approach 

In the preoperative planning phase, every child undergoes a comprehensive evaluation to assess transplant suitability and determine the ideal timing for VAD implantation. Early implantation is preferred over extracorporeal membrane oxygenation (ECMO) to avoid further deterioration. 

In this case, anesthesia was carefully managed due to patient fragility. A median sternotomy was performed, followed by thymectomy and pericardiotomy to optimize access. Minimal pleural dissection was maintained to reduce postoperative adhesions.  
While the VAD was primed and deaired, cardiopulmonary bypass (CPB) was established via aorto-right atrium cannulation. In ECMO-supported patients, venous drainage is enhanced through inferior vena cava (IVC) cannulation. 

Concurrent cardiac repairs, such as atrial septal defect (ASD) closure, are performed on CPB as needed. The left ventricular (LV) apex was carefully prepared, and the inflow cannula was positioned to avoid the mitral valve and trabeculae. The cannula was secured, and the tubing was brought out through the diaphragm, ensuring hemostasis and organ protection. 

A graft was attached to the ascending aorta, and the outflow cannula was tunneled and connected securely. The system was deaired again before full activation, and the VAD was ramped up gradually while weaning off CPB. Intraoperative transesophageal echocardiography (TOE) confirmed cannula positioning and function. Anti-adhesion strategies include placing a Gore-Tex membrane near the apex and a plastic sleeve around the graft. 

CPB cannulas were removed, hemostasis was ensured, drains were placed, and the chest was closed. The patient was transferred to the cardiac intensive care unit (CICU) for close monitoring, with the aim of early extubation and mobilization. 

Outcomes (2014–2024) 

Out of 173 VADs implanted, 117 successfully underwent heart transplantation. Six patients remain on VAD support. Dilated cardiomyopathy was the primary indication for VAD implantation, accounting for 67.6 percent of cases. The average patient weight was 21.9 kg, with many requiring ECMO before surgery. Common complications included neurological, coagulation, and renal issues. However, neurological complications dropped significantly after 2016 due to improved anticoagulation protocols. 

Conclusion 

GOSH’s evolving protocol for VAD implantation has delivered outstanding outcomes in pediatric heart failure. The proactive, team-based approach and continual improvements in surgical and medical management have enabled long-term support for critically ill children, significantly increasing transplant opportunities and survival rates. 

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