My Worst Nightmare: Primary Graft Dysfunction After Complicated Heart Transplantation For Congenital Heart Disease
Bahaaldin Alsoufi, Erle Austin, Sarah Wilkens, Andrea Nicole Lambert, Deborah Kozik.
University of Louisville, Louisville, KY, USA.
8Y old child, weight 17kg, had multiple cardiac surgeries for DORV, listed for heart transplantation (HT) for LV failure. He underwent LVAD for elevated PVR with excellent rehabilitation and decreased PVR. HT was complicated by primary graft dysfunction (PGD), thus transitioned from CPB to ECMO and that was complicated by bleeding requiring numerous explorations, plus renal failure. 12-days later, with no recovery and ongoing bleeding on ECMO, he was transitioned to BiVAD support using total artificial heart (TAH) configuration, since this would potentially allow bleeding control and importantly immunosuppression discontinuation. The ventricular mass was excised. Two 20mm porcine valved conduits were sutured to atrio-ventricular annuli and connected to EXCOR size-9 apical cannulas. Dacron grafts were sutured to aorta and PA and connected to EXCOR size-9 apical cannulas. Cannulas were connected to centrifugal pumps. The chest was closed after placing breast implant prosthesis to maintain pericardial space. Eventually 30cc EXCOR pumps were used. Support was maintained for 8-months. The patient participated in rehabilitation and overcome numerous complications however had persistent renal failure and eventually deterioration with sepsis. Given the lack of exit strategy, support was discontinued.
Discussion: Candidacy, timing and type of mechanical support for PGD are subject to discussion. While initial TAH objectives were met, this has not led to successful exit strategy. TAH configuration could be part of surgeon's armamentarium in better selected patients. 
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