HeartWare Ventricular Assist Device Implantation in Patients With Fontan Physiology

Abstract

We aim to describe the clinical course of a series of patients with hypoplastic left heart syndrome and refractory systolic heart failure supported with a HeartWare ventricular assist device (HVAD) following Fontan palliation. This is a retrospective review of three consecutive patients supported with a HVAD following Fontan palliation through February 2016. Data include patient characteristics, operative variables, postimplantation hemodynamic/device parameters, event outcomes, and duration of HVAD support. Patient ages were 11.7, 13.5, and 17.5 years, respectively, at the time of HVAD implant. The duration of HVAD support was 148, 272, and 271 days, respectively, of which 86, 222, and 211 were outpatient days. Inflow cannula position was the morphologic right ventricle with depth adjustment and manipulation of the tricuspid subvalvar apparatus to ensure good inflow. Echocardiographic, hemodynamic, and noninvasive oximetric monitoring resulted in high RPM settings for all patients. Despite various complications, all patients were successfully transplanted and discharged home alive. We present three patients bridged to transplantation using the HVAD following Fontan palliation. We demonstrate potential for durable support with transition to outpatient care while awaiting heart transplantation in a subset of patients status post Fontan surgery.

Hypoplastic left heart syndrome: from fetus to fontan

“…95 Multiple single-centre reports have shown success with various modalities for supporting the failing Fontan. [115][116][117] In a recent report from the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMAX), of 16,182 adult patients, only 17 (0.1%) had a functionally univentricular heart defect. However, survival for these 17 patients (~70% at 12 months) was similar to adult congenital heart patients with two ventricles and with that of adults without CHD.…”

An overview of mechanical circulatory support in single-ventricle patients

“…These CF devices, while originally designed for adults, have been used extensively in pediatrics (39,40). Their use in patients with a single-ventricle remains quite limited, though there are case reports (33)(34)(35). In pediatric patients, practice has recently shifted to CF devices in patients large enough to support one (41).…”

“…This will allow the cannula to be far enough from the septum and atrioventricular valve to avoid suck down events. In pediatric patients, especially if the ventricular muscle is thinned, the depth of the inflow cannula can be decreased by placing multiple felt rings on the epicardium (35). This latter approach has also been taken with cannulation of the common atrium using the HVAD, successfully bridging Fontan patients to transplant (58).…”

“…Indeed, many reports exist demonstrating survival to transplant for both PVF (33,34) and IVF (35). Considering that the vast majority are case reports, a substantial publication bias probably gives a false impression of the success rate.…”

Progress in experimental and clinical subpulmonary assistance for Fontan circulation

“…57 Clinical application of VADs in patients with failing Fontan circulation is almost universally relegated to support of systemic arterial blood flow. [58][59][60][61][62][63][64][65][66][67][68][69] At our institution, we used a VAD to facilitate Fontan completion in a patient with Glenn physiology and severe ventricular dysfunction. 70 A recent article demonstrated the promise of temporary, catheter-based VAD support of the failing systemic ventricle.…”