HeartMate 3 Implantation And DKS Remodeling In A Fontan Patient With Severe Neo-AI As A Bridge To Heart-Liver Transplantation
Karthik Thangappan, MD, Awais Ashfaq, MD, Alan ODonnell, PA-C, Ryan Moore, MD, Nicholas Szugye, MD, James S. Tweddell, MD, David L. S. Morales, MD.
Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
Using a VAD as a bridge to heart transplantation (BTT) or as chronic therapy in Fontan patients remains challenging but is increasing. A 22 year-old man cared for at another institution with a history of double outlet right ventricle with mitral atresia, s/p Norwood procedure, s/p bidirectional Glenn, s/p tricuspid valve repair at 3yo and then fenestrated Fontan (4yo), transferred care to our institution recently with severe Fontan liver disease and severely elevated Fontan pressures, worsening ventricular dysfunction, severe tricuspid regurgitation, and moderate/severe aortic regurgitation and remained quite symptomatic despite chronic milrinone. He was listed for heart-liver transplantation with a decision to BTT using a HeartMate 3 (HM3). The neo-aortic root was severely dilated at 6cm and thinned-out. The native aortic valve was 16cm with an ascending aorta before the DKS connection of almost 2cm. Because this was a BTT to en-bloc Heart-Liver where we would want to minimize ischemic time, we sewed a graft to the innominate artery (to be used now & at transplant) and took down the DKS to oversew the neo-aortic valve and re-shape it into a 2cm ascending aorta allowing for an easier transplantation. As per our routine for Fontan VADs, we created a 4mm fenestration. The inflow cannula was able to be sewed to the ventricular apex and the outflow was anastomosed to the lateral ascending aorta. The patient was extubated within 36 hours and is currently waiting at home for en-bloc heart-liver transplantation.
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