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Two Ecmo Runs, Two Lvad Implants, Two Transplants Back To Back. Can One Infant Endure?
Umar Boston, MD, John Karamichalis, MD, Christopher Knott-Craig, MD.
Le Bonheur Children's Hospital and University of Tennessee Health Science Center, Memphis, TN, USA.

Objective(s):
Surgical strategies in infants with complex heart failure pose significant challenges. When faced with unexpected circumstances, surgical decisions may become a surgeonís worst nightmare. Methods and Results:
A male infant presented with fulminant myocarditis secondary to parvovirus requiring VA-ECMO. After 3 days of ECMO he was transitioned to an LVAD with subsequent myocardial recovery warranting VAD explant 3 weeks later. Persistent parvovirus myocarditis with myocardial ischemia became evident four weeks later, with recurrent severe heart failure necessitating re-implantation of the LVAD and listing for heart transplantation. A donor heart became available; given current modified procuring practices due to Covid-19, the heart was procured through a third-party team using alternative preservation techniques to our protocol. Upon implantation, the donor heart developed severe primary graft dysfunction requiring VA-ECMO and immediate relisting for redo transplant. Following 5 days on ECMO with persistent severe graft dysfunction, a plan for potential BiVAD support was made while awaiting a donor. A marginal donor heart became available and was procured by our team. The re-transplant of the infant was a success. Conclusions:
Complementary use of ECMO and VAD strategies are essential in managing infants who present with severe heart failure. Multiple runs of ECMO and VAD support followed by severe graft dysfunction warranting immediate re-transplant is a surgeonís worst nightmare. The Covid-19 era has changed heart transplant practices. Employing alternative approaches to procurement practices may require standardization. Utilizing marginal donors may offer crucial exit strategies in dire circumstances with benefits in urgent relisting for transplant.


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