Transdiaphragmatic Abdominal Pericardial Extension: "TRAP Door" Facilitates Intrapericardial LVAD Placement
Patrick McConnell, Sergio Carrillo, MD.
Nationwide Childrens, Columbus, OH, USA.
Objective(s): Recent changes in the availability of small intrapericardial left ventricular assist devices (LVAD) has resulted in difficulties with fitting these adult devices in small children. We have made modifications to a procedure to expand the pericardium used for older, and much larger LVADs in adults. Methods: Our video submission describes the technique of TRansdiaphragmatic Abdominal Pericardial extension or, so called, "TRAP door" to facilitate the intrapericardial placement of LVADs in small patients.Results: TRAP door creation requires folding a 20 x 15 cm sheet of 0.1mm PTFE membrane lengthwise and suturing the long-edge and one short edge to create a PTFE tube. This tube is positioned abdominally through a 2 cm opening in the peritoneum after sternotomy. A series of endoGIA staplers are used to staple through the diaphragm and the long-axis of the tube on a tangent to the pericardial apex. The PTFE tube is sutured to isolate the pericardium from the abdomen. Three obese children (BSA 1.2 to 1.7 m2; ages 7, 9 and 13 years have under gone TRAP door with HeartMate 3 placement and subsequent transplant with reversal of the TRAP door. Routine post-transplant chest fluoroscopy has demonstrated normal diaphragm function in all patients.
Conclusions: The TRAP door technique effectively enlarges the pericardial space allowing for a completely intrapericardial LVAD implant avoiding the difficulties of extra pericardial LVAD implantation. It effectively eliminates the LVAD chest wall interaction and is easily reversed at transplant without impacting diaphragm function either during LVAD support or after explant and transplant.
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