HeartMate 3™ Implant in Pediatric Patient With Dilated Cardiomyopathy

2019-12-16T21:01:47Z (GMT) by David Morales Alan ODonnell

The patient was a 10-year-old, 26.7 kg, girl with dilated cardiomyopathy. The patient had a familial history and was admitted to an outside hospital in decompensated heart failure. She had complaints for two days of severe abdominal pain, nausea, and vomiting, and was tolerating minimal PO intake. She was tachycardic with waxing and waning perfusion throughout her stay. An abdominal computed tomography scan was performed to evaluate her abdominal pain, which identified bilateral pleural effusions and cardiomegaly. A transthoracic echocardiogram was then obtained, which demonstrated a severely dilated left ventricle and an ejection fraction of 18%. Infusions of epinephrine and milrinone were initiated. Epinephrine was discontinued due to idioventricular rhythms. The patient had one run of SVT that terminated with a dose of adenosine. The patient was also given one dose of IVIG. Despite medical management, her symptoms persisted and even worsened.

The patient was transferred to Cincinnati Children’s Hospital Medical Center (CCHMC) for further management. Milrinone (0.75 mcg/kg/min) infusion was continued and calcium (5 mg/kg/hr) infusion was initiated. A diuretic regimen was initiated as well. Despite maximal medical therapy, the patient’s status continued to decline. The patient met requirements for ventricular assist device implantation by being supported by two inotropes and being intolerant of PO intake despite diuresis. She was discussed at a case management conference and the decision was made to obtain cross-sectional imaging and evaluate her candidacy for a left ventricular assist device as a bridge to heart transplant. The HeartMate 3™ was selected as the device of choice for mechanical support. The main question was whether or not the device would fit in this particular patient due to her size (BSA: 1.042 m2).

With the help of the Media Lab at Cincinnati Children’s Hospital, 3D reconstructions were created. Virtual reality was utilized to simulate HeartMate 3™ placement in the patient’s chest (video). Ultimately, it was decided that she was of adequate size to tolerate the device.

Ten days following transfer to CCHMC, the HeartMate 3™was implanted in the patient (video) without incident. A special controller was used to potentially lower settings as needed.

Initial VAD settings postoperatively were:

  • RPM: 5000
  • Flow: 3.5 - 4 L/min
  • PI: 5 – 7

The patient had a relatively uncomplicated postoperative course and was discharged home on postoperative day 31 listed for Status 1A for heart transplant. The patient was well supported on the HeartMate 3™ for 46 days before ultimately receiving a heart transplant. The patient did well following heart transplantation, was discharged on postoperative day 28, and is currently doing well as an outpatient.

Special thanks to Dr Ryan Moore and the Cincinatti Children’s Media Lab for providing 3D reconstruction and virtual reality fit-testing footage.