Implantation of Total Artificial Heart in Congenital Heart Disease

This video summarizes a modified procedure used to implant a total artificial heart in a patient with a history of congenitally corrected transposition of the great arteries, pulmonary atresia, and ventricular septal defect in contrast to a normal heart. The anatomy of this patient's heart presented a challenge to TAH implantation, as it is characterized by l looped ventricles, a morphologic left ventricle on the right side, and vice versa, as well as transposed grade arteries with the aorta anterior and leftward to the pulmonary artery. In patients with normally structured hearts, the TAH replaces the ventricles in a crisscrossed arrangement for the patient with transposed arteries and inverted ventricles.

The surgical plan included modification of the TAH such that the right and left pumps were implanted in a parallel orientation. The patient in this case report was able to return home and regain health and strength prior to being successfully bridged to heart transplantation five months after receiving the device. Demonstrating that with technical modification, TAH is feasible even in patients with structurally abnormal hearts.

The advantage of the total artificial heart is that in fact, you take the entire heart out and you're placing a total artificial heart, unlike many of the mechanical devices that we have now, which actually help the heart, while it's still in situ to patients have tried to be supported with VADs or ventricular assist devices in the past. The problem being is that you have to continue the immune suppression. However, with the total artificial heart, you can take the whole heart out and stop the immune suppression.

So I feel this would be a more successful way to bridge patients who have chronic rejection to heart transplant. There are certain congenital heart surgery patients or congenital heart patients who have multiple defects. It would be much easier to take out the whole heart and only do one procedure, which is the placement of the total artificial heart, and that's what we're gonna talk about today.

In this case, CT scans show the patient had C-C-T-G-A with L looped ventricles and transposed great arteries, severe aortic insufficiency and obstruction of a conduit between the left ventricle and pulmonary artery. The cardiac me began with standard preoperative patient preparation in the normal sterile fashion for the repeat sternotomy following dissection of the diaphragmatic surface. The aorta, the right femoral vein and the superior vena CVA were dissected and cannulated.

The patient was then placed on bival cardiopulmonary bypass. The inferior vena CVA was dissected and the aorta was cross clamped. This allowed complete decompression of the heart.

The aorta and the main pulmonary artery were then divided after dissecting the rest of the ventricular surface, the main pulmonary artery, the pulmonary artery branch, and the proximal pulmonary artery branches. The right ventricle was dissected out approximately three to four millimeters of muscle was left below the right atrial ventricular valve. The left ventricle was then dissected out, leaving a three to five millimeter cuff, a ventricular muscle below the left atrial ventricular valve, using a large proline on an MH needle.

The previously prepared felt strip with goretex was whip stitched to fortify the muscular rim of the ventricular muscle cuffs, and the atrial quick connect was trimmed to a three to four millimeter rim. It was inverted and sewn to the muscular cuff, both on the left and right sides to prevent scalloping. The ventricles were tunneled out, just left of the midline and outflow graft were cut to the appropriate size.

Then the aorta and pulmonary artery cuffs were sewn using running sutures before excising the right ventricle to pulmonary artery, conduit, and calcified areas. After the atrial cuffs were tested for leaks and the aorta and pulmonary artery anastomosis were tested under pressure, a driveline tunnel was created. The left TAH ventricle was then connected to the left atrial cuff and then to the aorta.

Then the outflow graft of the aorta was connected to the system and the cross clamp was released slowly after this. The TAH right ventricle was connected to the atrial cuff of the right atrium and then to the pulmonary artery. In the final position, the TAH ventricles were aligned in a parallel fashion because the pulmonary artery graft did not cross over top of the aortic graft due to the TGA anatomy Following complete attachment of the TAH device, the device was turned on after achieving homeostasis.

The patient was taken off cardiopulmonary bypass and four chest tubes were placed prior to closing the patient. As detailed in the text protocol, previously, patients with malformed hearts were not considered candidates for receiving a TAH due to the challenges presented by the unusual anatomy. This video shows that with technical modification, the TAH can be successfully implanted in a patient with C-C-T-G-A.

The reason we were able to discharge Jordan is because of the freedom driver, which is a new driving system for the total artificial heart, which he can carry in a backpack or a satchel. And this allowed him to go home and like all good Texans, he even went hunting and fishing with his device while awaiting his transplant. He eventually, after being supported for approximately three months, came back and successfully had his transplant.

And what was most noticeable is the different state of health that he was in when he came for his transplant. His ability to rehabilitate, to gain weight, to gain muscle mass, and really to be in much better spirits than he would've been if he had gone straight to transplant with the total artificial heart was probably what was most noticeable by myself and the staff. So after the transplant, which was successful, he was able to be discharged home and now is starting College.