Name: implantation of total artificial heart in congenital heart disease
Uploaded: 2014-07-18T06:00:00.000+00:00
Duration: 7 min 27 s
Description: Watch this Scientific Journal Video about Implantation of Total Artificial Heart in Congenital Heart Disease at JoVE.com

1. Pre-operative Patient Preparation
<ol>
	<li>The patient was given general anesthesia according to standard procedures.</li>
	<li>He was placed on the operating table in supine position.</li>
	<li>The right neck line and a right atrial PICC line were removed.</li>
	<li>He received central access in the left femoral vein and remained with his arterial line.</li>
	<li>A TEE probe was placed and demonstrated severely depressed biventricular function and significant aortic insufficiency.</li>
</ol>
2. Cardiectomy
<ol>
	<li>The patient was positioned, prepped and draped in the normal sterile fashion for the repeat sternotomy.</li>
	<li>The repeat sternotomy was completed (Figure 4). Immediately noticeable was the extremely enlarged heart and severe adhesions.</li>
	<li>The diaphragmatic surface was dissected out. It was severely adhered secondary to epicardial wires. The patient would not tolerate significant movement of the heart in trying to reach the inferior vena cava (IVC).</li>
	<li>The aorta was dissected.</li>
	<li>The right femoral vein was dissected.</li>
	<li>Pursestrings were placed in the aorta and femoral vein, heparin was administered, and the aorta and right femoral vein were cannulated. The tip of the venous cannula was advanced to the IVC.</li>
	<li>After reaching appropriate activated clotting time (ACT), the patient went onto cardiopulmonary bypass. Since his systemic vascular resistance was markedly elevated due to severe heart failure, aggressive afterload reduction was required to achieve adequate perfusion pressure.</li>
	<li>The patient was placed with an MPA vent to achieve better decompression of the left heart. However, it became obvious with full flow that this would be a difficult hemodynamic circuit to keep stable primarily due to significant aortic insufficiency.</li>
	<li>The superior vena cava (SVC) was dissected and cannulated, and the patient was placed on bicaval cardiopulmonary bypass&#160;(Figure 5).</li>
	<li>The IVC was dissected and the aorta was cross-clamped. This allowed complete decompression of the heart.</li>
	<li>The aorta and the main PA were divided (Figure 6).</li>
	<li>The rest of the ventricular surface including the diaphragmatic surface, left atrial gutter, and right atrial gutter was dissected out. The MPA, the PA branch and the proximal PA branches were also dissected.</li>
	<li>The right ventricle was dissected out, leaving approximately 3-4 mm of muscle below the right AV valve&#160;(Figure 7A).</li>
	<li>The left ventricle was dissected out leaving a 3-5 mm cuff of ventricular muscle below the left AV valve (Figure 7B).</li>
</ol>
3. TAH Implantation
<ol>
	<li>Using a large Prolene on an MH needle, the previously prepared felt strip with Gore-Tex was whip-stitched to fortify the muscular rim of the ventricular muscle cuffs.</li>
	<li>The atrial quick-connect was trimmed to a 3-4 mm rim. It was inverted and sewn to the muscular cuff both on the left and right sides, to prevent scalloping (Figure 8).</li>
	<li>The ventricles were tunneled out just left of the midline and outflow grafts were cut to the appropriate size.</li>
	<li>The Ao and PA cuffs were sewn using running sutures (Figure 9).</li>
	<li>The RV to PA conduit and calcified areas were excised.</li>
	<li>The atrial cuffs were tested for leaks, and then the Ao and PA anastomoses were tested</li>
	<li>A driveline tunnel was created (Figure 10).</li>
	<li>The left TAH ventricle was connected to the left atrial cuff and then to the aorta (Figure 11).</li>
	<li>Then the outflow graft of the Ao was connected to the system and the cross clamp was released slowly (Figure 12a).</li>
	<li>After this, the TAH right ventricle was connected to the atrial cuff of the RA and then to the PA (Figure 12b).</li>
	<li>In the final position, the TAH ventricles were aligned in a parallel fashion because the PA graft did not cross over top of the aortic graft due to the TGA anatomy (Figure 13).</li>
	<li>The right ventricle was de-aired by removing the IVC snare, an active root vent was placed in the ascending Ao and rewarming was completed.</li>
	<li>The lungs were suctioned and ventilated and the TAH was turned on to de-air the active root vent in the ascending Ao.</li>
	<li>The patient was taken off cardiopulmonary bypass, and the rate of the TAH was increased.</li>
	<li>After achieving good hemodynamics and giving protamine, the heart was decannulated.</li>
	<li>Once hemostasis was achieved, four chest tubes were placed: two Blakes in the mediastinum and posterior mediastinum, one large 40 chest tube in the anterior mediastinum, and a right-angle chest tube in the left chest.</li>
	<li>A neopericardium made of thin Gore-Tex was created and placed around the device. Once completed, the entire mediastinum was irrigated with copious amounts of warm antibiotic saline solution.</li>
	<li>The sternum was closed with surgical steel wires, while making sure sternal closure did not cause any compression to the TAH. The skin and underlying tissues were closed in layers.</li>
	<li>After gaining hemostasis in the groin, this area was closed.</li>
	<li>The AICD pocket was cultured, the AICD removed, and a small drain was placed in the pocket.</li>
	<li>The patient tolerated this very complex procedure well and was transferred to the CVICU in a stable hemodynamic and respiratory state. The patient was extubated on postoperative day 2. Unlike management for ventricular assist device, postoperative care TAH does not require inotropes. Fluid control and afterload reduction are the main parts of postoperative care. Anticoagulation was commenced at day 2 per the manufacture&#39;s protocol.</li>
</ol>

<ol>
	<li>Kirsch, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=SynCardia+temporary+total+artificial+heart+as+bridge+to+transplantation:+current+results+at+la+piti&#233;+hospital.">SynCardia temporary total artificial heart as bridge to transplantation: current results at la piti&#233; hospital.</a> Ann Thorac Surg. 95 (5), 1640-1646 (2013).</li><li>Copeland, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Total+artificial+hearts:+bridge+to+transplantation.">Total artificial hearts: bridge to transplantation.</a> Cardiol Clin. 21 (1), 101-113 (2003).</li><li>Roussel, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=CardioWest+(Jarvik)+total+artificial+heart:+a+single-center+experience+with+42+patients.">CardioWest (Jarvik) total artificial heart: a single-center experience with 42 patients.</a> Ann Thorac Surg. 87 (1), 124-129 (2009).</li><li>Slepian, M., Alemu, Y., Soares, J., Smith, R., Einav, S., Bluestein, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+Syncardia+total+artificial+heart:+in+vivo,+in+vitro,+and+computational+modeling+studies.">The Syncardia total artificial heart: in vivo, in vitro, and computational modeling studies.</a> J Biomech. 46 (2), 266-275 (1016).</li><li>Koyak, Z., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Sudden+cardiac+death+in+adult+congenital+heart+disease.">Sudden cardiac death in adult congenital heart disease.</a> Circulation. 126 (16), 1944-1954 (2012).</li><li>Shaddy, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Applying+heart+failure+guidelines+to+adult+congenital+heart+disease+patients.">Applying heart failure guidelines to adult congenital heart disease patients.</a> Expert Rev Cardiovasc Ther. 6 (2), 165-174 (2008).</li><li>Warnes, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transposition+of+the+great+arteries.">Transposition of the great arteries.</a> Circulation. 114, 2699-2709 (2006).</li><li>Rutledge, J., Nihill, M., Fraser, C., Smith, O., McMahon, C., Bezold, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Outcome+of+121+patients+with+congenitally+corrected+transposition+of+the+great+arteries.">Outcome of 121 patients with congenitally corrected transposition of the great arteries.</a> Pediatr Cardiol. 23, 137-145 (2002).</li><li>Graham, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Long-term+outcome+in+congenitally+corrected+transposition+of+the+great+arteries:+a+multi-institutional+study.">Long-term outcome in congenitally corrected transposition of the great arteries: a multi-institutional study.</a> J Am Coll Cardiol. 36, 255-261 (2000).</li><li>Voskuil, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Postsurgical+course+of+patients+with+congenitally+corrected+transposition+of+the+great+arteries.">Postsurgical course of patients with congenitally corrected transposition of the great arteries.</a> Am J Cardiol. 83, 558-562 (1999).</li><li>Hoffman, J., Kaplan, S., Liberthson, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prevalence+of+congenital+heart+disease.">Prevalence of congenital heart disease.</a> Am Heart J. 147 (3), 425-439 (2004).</li><li>Marelli, A., Mackie, A., Ionescu-Ittu, R., Rahme, E., Pilote, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Congenital+Heart+Disease+in+the+General+Population:+Changing+Prevalence+and+Age+Distribution.">Congenital Heart Disease in the General Population: Changing Prevalence and Age Distribution.</a> Circulation. 115, 163-172 (2007).</li><li>DiNardo, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Heart+failure+associated+with+adult+congenital+heart+disease.">Heart failure associated with adult congenital heart disease.</a> Semin Cardiothorac Vasc Anesth. 17, 44-54 (2013).</li></ol>

Production of this video-article was sponsored by SynCardia.

The TAH is designed as a bridge to cardiac transplant for patients with normally structured hearts. It enables patients to regain health and stamina as they await a donor heart. Previously, patients with malformed hearts were not considered candidates for receiving a TAH due to the challenges presented by the unusual anatomy. This article highlights that the TAH, with modification, is a viable option for patients with CCTGA, a congenital condition which features l-looped ventricles and transposed great arteries in the setting of usual atrial arrangement. Implanting the TAH in a patient with CCTGA requires a technical modification, with the right and left pumps implanted in a parallel orientation instead of the typical crossed arrangement.
The report also demonstrates that the TAH may provide a simpler solution than placement of VADs in critically ill patients with complex cardiac lesions. In this case, the patient had severe AI and obstruction of a conduit between the LV and PA. The TAH was considered a better option than support with a VAD, which would have required multiple concomitant surgical procedures. 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 TAH.
With advances in medical and surgical treatment, increasing numbers of patients with CHD are surviving to adulthood11,12. The prevalence of adults with severe CHD increased 85% between 1985 and 200012. The population of adults with CHD now outnumbers that of children with CHD, and a significant subset of this adult population has an increased risk of HF13. As demonstrated in this case, the TAH provides an additional option for CHD patients with HF. In the light of the increasing number of adult patients with HF due to congenital heart disease, this case should represent the beginning of the new era of mechanical circulatory support for those with malformed hearts.

The total artificial heart (TAH) was developed as a bridge to cardiac transplant in patients with heart failure (HF)1-4. The device is a mechanical circulatory support system which replaces the ventricles, with the purpose of extending life until a suitable donor heart becomes available. Congenital heart conditions may sometimes lead to HF, with patients requiring circulatory support5,6.&#160;In individuals with CCTGA, the aorta and pulmonary artery (PA) are transposed and the ventricles are inverted7. The condition may eventually cause HF due to an inability of the morphologic right ventricle (RV) to pump against systemic vascular resistance8-10.
In the case presented here, the patient underwent multiple childhood surgeries for his CCTGA, including a Rastelli repair and a subsequent transvenous dual chamber pacing system. As a teenager, he developed symptoms of HF due to dysfunction of the systemic RV. His condition was complicated by the presence of severe aortic insufficiency (AI) and obstruction of the conduit placed between the left ventricle (LV) to PA. After multiple hospitalizations, including placement with an implantable cardioverter defibrillator (ICD), he advanced to end-stage HF and went into renal failure and cardiogenic shock, requiring intubation and circulatory support.
Although the TAH is designed for individuals with normally-structured hearts, the device was considered the patient&#8217;s best option for survival considering the severity of his condition and the presence of complex cardiac lesions. To accommodate his transposed arteries and inverted ventricles, the TAH was modified during implantation, and the surgery was successful. Three months after implantation, he was discharged home. He received a donor heart 5 months after implantation with the TAH.
Case Presentation:
The patient was a 17-year-old Caucasian male with a history of CCTGA, pulmonary atresia, and ventricular septal defect (VSD) (Figures 1A&#160;and 1B). He had an ascending aorta to main pulmonary artery shunt and epicardial pacemaker placed in infancy. At age 4, he underwent classical (Rastelli) repair, consisting of VSD closure and placement of a morphologic LV to PA conduit. A residual VSD was closed with an Amplatzer occluder at age 11. He subsequently received a dual chamber transvenous pacing system. At age 16, he was treated with cardiac resynchronization therapy (CRT).
At age 17, the patient presented to the emergency room (ER) with dyspnea after several days of noncompliance with medication. He reported having a brief episode of chest pain four days prior to the ER visit. The patient was treated with diuretics overnight and was discharged home with medications re-established. Following his hospitalization, cardiac transplantation was discussed in detail with the patient and his family. A complete transplant evaluation was performed and the patient was subsequently listed.
Nine months later, he was admitted to the hospital after an episode of syncope associated with atrial fibrillation. He underwent direct current (DC) cardioversion. Four days after being discharged, he returned to the ER with complaints of chest pain and hemoptysis. He subsequently returned two days later, reporting increased chest pain. Computerized tomography (CT) revealed a pulmonary embolus in a right lower lobe distribution as well as a separate infiltrate. Anticoagulation therapy was initiated. Two weeks later, an implantable cardioverter defibrillator (ICD) was placed following a period of nonsustained ventricular tachycardia.
The patient was discharged nine days after ICD placement but returned four days later complaining of recurrent episodes of dyspnea and palpitations at night when lying down, as well as chronic nausea and decreased appetite. He was re-admitted at this time. His entering medications were digoxin 125 microgram po daily, hydrochlorothiazide 25 mg po daily, warfarin 5.5 mg po daily, enalapril 10 mg po twice daily, furosemide 40 mg po twice daily, and metoprolol 50 mg po twice daily. He was taking Zofran, Colace, Miralax, and Tylenol on an as needed basis. He had no known drug allergies.
Cardiovascular examination was significant for diffuse point of maximal impulse. On auscultation, there was a regular rhythm with a single S1 and fixed, split S2. There was a grade IV/VI, to/fro, systolic/diastolic murmur at the left sternal border. Vitals were heart rate 94, blood pressure 98/54. Lungs were significant for decreased breath sounds at the right base. Chest x-ray revealed severe cardiomegaly with severely congested lung fields. There was a small right pleural effusion<s>.</s> Bloodwork was significant for progressive hyponatremia, an increase in BNP, and a mild increase in his BUN. The patient was noted to have severely depressed biventricular systolic function, and at least moderate conduit obstruction.
The patient&#8217;s HF continued to progress in the following few weeks, with multiple admits to the intensive care unit. After an episode of syncope following arrhythmia, he was admitted and placed on milrinone. He remained milrinone-dependent in the hospital but continued to have progressive HF symptoms. Over a 48&#160;hr period, he went into severe HF with renal failure and required intubation. Within 24 hours of intubation, heart dysfunction progressed, with worsening perfusion. He stopped producing urine, his creatinine began to rise, and he became hypotensive.
Diagnosis, Assessment, and Plan:
The patient was diagnosed with severe HF and cardiogenic shock secondary to CCTGA, status post classic repair. Secondary diagnoses included morphologic LVOT obstruction and VSD. Despite the challenge presented by his congenitally malformed heart, emergent TAH implantation was considered his best chance for survival given his critical condition and complex cardiac adhesions. The alternative solutions of placing extracorporeal membrane oxygenation (ECMO) through the groin or a temporary ventricular assist device (VAD) through the chest or groin were ruled out due to his severe AI and LVOT obstruction. It was felt that stopping the heart and attempting to place a VAD, while also changing the LV to PA conduit and the aortic valve, would not be a viable option and the patient would likely require a biventricular assist device (BiVAD). Dopamine was added to the milrinone to stabilize the patient&#8217;s blood pressure prior to the surgery.
The surgical plan included modification of the TAH, such that the right and left pumps were implanted in a parallel orientation instead of the normal criss-cross arrangement (Figures 2A, 2B,&#160;and 2C). The major determinants of this unusual orientation were l-looped ventricles (a morphologic left ventricle on the right side and vice-versa) and transposed great arteries, with the aorta anterior and leftward to the pulmonary artery (Figures 3A&#160;and&#160;3B).

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implantation of total artificial heart in congenital heart disease

In patients with end-stage heart failure (HF), a total artificial heart (TAH) may be implanted as a bridge to cardiac transplant. However, in congenital heart disease (CHD), the malformed heart presents a challenge to TAH implantation. 
In the case presented here, a 17 year-old patient with congenital transposition of the great arteries (CCTGA) experienced progressively worsening HF due to his congenital condition. He was hospitalized multiple times and received an implantable cardioverter defibrillator (ICD). However, his condition soon deteriorated to end-stage HF with multisystem organ failure. 
Due to the patient's grave clinical condition and the presence of complex cardiac lesions, the decision was made to proceed with a TAH. The abnormal arrangement of the patient's ventricles and great arteries required modifications to the TAH during implantation.
With the TAH in place, the patient was able to return home and regain strength and physical well-being while awaiting a donor heart. He was successfully bridged to heart transplantation 5 months after receiving the device. This report highlights the TAH is feasible even in patients with structurally abnormal hearts, with technical modification.

The patient tolerated the TAH procedure well and three months later he was discharged home with a portable driver. Regular TAH outpatient protocol was followed during this time, including physical and occupational therapy.
Six weeks after discharge, he was admitted after hypertensive crisis caused his driver to function poorly, resulting in reduced cardiac output. He was admitted, emergently intubated and switched over to the Big Blue driver, which re-established good output from the TAH. His condition improved over the course of a few days. He was being re-established on warfarin while awaiting a new portable driver when a suitable donor heart became available and the patient was taken for transplantation. Plasmapheresis (net zero, using 4.2 L of FFP) was performed on the donor heart to clear donor-specific antibodies.
During the surgery, the patient was found to have severe adhesions. The aortic graft was adhered to the posterior sternum and dense adhesions surrounded the TAH. There were no signs of infection. The inferior vena cava (IVC) was very difficult to find because the right ventricle of the TAH was positioned anterior to the IVC. Because of the CCTGA, the PAs were dissected to provide full mobility and the great vessels were then connected in the correct orientation. Due to the abnormal orientation of the heart, especially the left atrium, the lateral side of the IVC was left slightly longer. Surgery was complicated by a significant bleeding from the oropharynx, which necessitated ENT evaluation and packing of the area prior to taking the patient off bypass. A left atrial line was placed through the left atrial anastomosis before coming off cardiopulmonary bypass. Once weaned off bypass, the heart function was quite good. An epicardial echocardiogram demonstrated that all valves were working well, as well as the function of both ventricles. Protamine was given. Meticulous care was taken to achieve hemostasis. The patient tolerated the procedure well and was transferred to the cardiovascular ICU in stable hemodynamic and respiratory state.
<img alt="3D CT scan of the heart and vessels, anatomical diagram, cardiovascular imaging analysis." fo:content-width="5in" src="/files/ftp_upload/51569/51569fig1.jpg" data-altupdatedat="1747911167000" data-alt="Figure 1"> 
Figure 1. Congenitally corrected transposition of the great arteries. Patient CT scans, with coronal view (A) and axial view (B) showing CCTGA with l-looped ventricles (a morphologic left ventricle on the right side and vice-versa) and transposed great arteries, with the aorta anterior and leftward to the pulmonary artery. A conduit was placed between the morphologic left ventricle and the pulmonary artery.
<img alt="Heart pump implant diagrams and CT scan, showcasing artificial heart positioning and vascular anatomy." fo:content-width="5in" src="/files/ftp_upload/51569/51569fig2.jpg" data-altupdatedat="1747911167000" data-alt="Figure 2"> 
Figure 2. TAH modification. TAH orientation in a normal adult heart, with pumps aligned in a crossed arrangement (A), and modified orientation in a heart with CCTGA (B). Due to abnormal orientation of the great vessels, the pumps need to be in parallel orientation, as seen in the CT (C).
<img alt="Human heart anatomy comparison; diagram of chambers and valves, illustrating structural differences." fo:content-width="5in" src="/files/ftp_upload/51569/51569fig3.jpg" data-altupdatedat="1747911167000" data-alt="Figure 3"> 
Figure 3. CCTGA Anatomy. Normal arrangement of great vessels and ventricles (A), and the anatomical abnormality in CCTGA (B), with the Ao and PA transposed and the ventricles inverted.
<img alt="Surgical procedure diagram showing sternum retractor for chest cavity access." fo:content-width="5in" src="/files/ftp_upload/51569/51569fig4.jpg" data-altupdatedat="1747911167000" data-alt="Figure 4"> 
Figure 4. Median Sternotomy. TAH implantation procedure began with a 5th repeat median sternotomy.
<img alt="Cardiac surgery diagram, illustrating open-heart procedure with surgical retractor and coronary arteries." fo:content-width="5in" src="/files/ftp_upload/51569/51569fig5.jpg" data-altupdatedat="1747911167000" data-alt="Figure 5"> 
Figure 5. Cannulation. The vessels were cannulated and the patient placed on bicaval cardiopulmonary bypass.
<img alt="Bypass surgery diagram: coronary artery grafting method on heart, medical educational illustration." fo:content-width="5in" src="/files/ftp_upload/51569/51569fig6.jpg" data-altupdatedat="1747911167000" data-alt="Figure 6"> 
Figure 6. Division of the Aorta and the main pulmonary artery. The aorta was clamped to stop the heart, prior to starting cardiectomy. The aorta and the main pulmonary artery were divided after aortic cross-clamping.
<img alt="Heart dissection process, surgical anatomy diagram, step-by-step procedural illustration." fo:content-width="5in" src="/files/ftp_upload/51569/51569fig7.jpg" data-altupdatedat="1747911167000" data-alt="Figure 7"> 
Figure 7. Excision of the Ventricles. The ventricles were excised (A), leaving a 3-5 mm cuff of ventricular muscle below the left and right AV valves (B).
<img alt="Heart valve surgery diagram, showing valve replacement procedure with surgical tools." fo:content-width="5in" src="/files/ftp_upload/51569/51569fig8.jpg" data-altupdatedat="1747911167000" data-alt="Figure 8"> 
Figure 8. Suturing of Atrial Cuffs. After closing the coronary sinus and left atrial appendage to prevent thrombus formation, the atrial cuffs were trimmed and sutured carefully with running suture.
<img alt="Heart surgery diagram; prosthetic valve implantation; surgical scissors; cardiology procedure." fo:content-width="5in" src="/files/ftp_upload/51569/51569fig9.jpg" data-altupdatedat="1747911167000" data-alt="Figure 9"> 
Figure 9. Anastomosis of Outflow Grafts. Running suture was used to anastomose outflow grafts to the Ao and PA.
<img alt="Artificial heart implant diagram with mechanical circulatory support devices and surgical placement." fo:content-width="5in" src="/files/ftp_upload/51569/51569fig10.jpg" data-altupdatedat="1747911167000" data-alt="Figure 10"> 
Figure 10. Completed Anastomosed Outflow Grafts. The TAH ventricles were brought into the field. The drivelines were passed through the skin.
<img alt="Heart bypass surgery diagram; prosthetic devices; cardiovascular repair; medical illustration." fo:content-width="5in" src="/files/ftp_upload/51569/51569fig11.jpg" data-altupdatedat="1747911167000" data-alt="Figure 11"> 
Figure 11. Attachment of Driveline Tunnels. Starting with the left side, the TAH was connected to the atrial cuff and then to the aorta.
<img alt="Heart assist device diagram; ventricular pump aiding blood flow in circulatory support." fo:content-width="5in" src="/files/ftp_upload/51569/51569fig12.jpg" data-altupdatedat="1747911167000" data-alt="Figure 12"> 
Figure 12. Release of Cross Clamp. After the left TAH ventricle was connected to the left atrial cuff and the aorta, the outflow graft was connected to the system and the cross-clamp was released slowly.
<img alt="Artificial heart valve implant diagram; depicts surgical placement and connection within heart." fo:content-width="5in" src="/files/ftp_upload/51569/51569fig13.jpg" data-altupdatedat="1747911167000" data-alt="Figure 13"> 
Figure 13. Final TAH position. The TAH pumps were oriented in a parallel fashion to accommodate the TGA anatomy.

Watch this Scientific Journal Video about Implantation of Total Artificial Heart in Congenital Heart Disease at JoVE.com

Implantation of Total Artificial Heart in Congenital Heart Disease

This is a case report of a patient with congenitally corrected transposition of the great arteries (CCTGA) who received a total artificial heart (TAH) as a bridge to heart transplant. The TAH was successfully implanted with modifications to accommodate the patient's congenitally malformed heart.

In patients with end-stage heart failure (HF), a total artificial heart (TAH) may be implanted as a bridge to cardiac transplant. However, in congenital ...

implantation-of-total-artificial-heart-in-congenital-heart-disease

Nanyang Technological University

Research

JoVE Journal

Medicine

24.4K Views.  Texas Children's Hospital. This is a case report of a patient with congenitally corrected transposition of the great arteries (CCTGA) who received a total artificial heart (TAH) as a bridge to heart transplant. The TAH was successfully implanted with modifications to accommodate the patient's congenitally malformed heart.

Video: Implantation of Total Artificial Heart in Congenital Heart Disease

Implantation of Engineered Tissue in the Rat Heart

Rodent surgery is often an important component in assessing the utility of engineered tissues. A wide variety of surgical procedures can be performed in common laboratory rats or mice and these quite frequently serve as an intermediate step between bench-top experiments and large animal testing or human trials. Given that rodents provide an established, cost-effective, and physiologically-relevant model system in which to test novel combinations of scaffolding materials and cells, they are particularly well-suited for cardiovascular tissue engineering studies. Presently, we describe an open-heart surgical procedure to implant engineered tissue containing myogenic progenitor cells in the atrioventricular (AV) groove of a rat heart. These implants are intended to create an electrical conduit between the right atrium and right ventricle with the ultimate goal of providing an alternative treatment to conventional pacemaker implantation in pediatric patients with complete heart block[1]. The engineered tissue is implanted in the AV-groove by means of a thoracotomy. For our purposes, Lewis rats are anesthetized and invasively ventilated to maintain positive airway pressure during the sterile surgical procedure. The approach to the heart is performed by a right thoracotomy through an antero-lateral incision at the 5th intercostal space. The tissue construct is fixed in the AV groove using a single 7-0 Prolene suture and positioned between the right ventricle and atrium at the ventral portion of the heart. The epicardium is partially removed to allow direct contact between the recipient myocardial cells and those contained in the engineered tissue. Following implantation, the chest wall is closed in layers, any pneumothorax is evacuated, and the animal is extubated and treated with analgesic.

Here, we describe a cardiac surgical procedure to implant engineered tissue in the atrioventricular (AV)-groove of an adult Lewis rat.

Rodent surgery is often an important component in assessing the utility of engineered tissues. A wide variety of surgical procedures can be performed in ...

Biology

Implantation of the Syncardia Total Artificial Heart

With advances in technology, the use of mechanical circulatory support devices for end stage heart failure has rapidly increased. The vast majority of such patients are generally well served by left ventricular assist devices (LVADs). However, a subset of patients with late stage biventricular failure or other significant anatomic lesions are not adequately treated by isolated left ventricular mechanical support. Examples of concomitant cardiac pathology that may be better treated by resection and TAH replacement includes: post infarction ventricular septal defect,&#160;aortic root aneurysm / dissection, cardiac allograft failure, massive ventricular thrombus, refractory malignant arrhythmias (independent of filling pressures), hypertrophic / restrictive cardiomyopathy, and complex congenital heart disease. Patients often present with cardiogenic shock and multi system organ dysfunction. Excision of both ventricles and orthotopic replacement with a total artificial heart (TAH) is an effective, albeit extreme, therapy for rapid restoration of blood flow and resuscitation. Perioperative management is focused on end organ resuscitation and physical rehabilitation. In addition to the usual concerns of infection, bleeding, and thromboembolism common to all mechanically supported patients, TAH patients face unique risks with regard to renal failure and anemia. Supplementation of the abrupt decrease in brain natriuretic peptide following ventriculectomy appears to have protective renal effects. Anemia following TAH implantation can be profound and persistent. Nonetheless, the anemia is generally well tolerated and transfusion are limited to avoid HLA sensitization. Until recently, TAH patients were confined as inpatients tethered to a 500 lb pneumatic console driver. Recent introduction of a backpack sized portable driver (currently under clinical trial) has enabled patients to be discharged home and even return to work. Despite the profound presentation of these sick patients, there is a 79-87% success in bridge to transplantation.

The purpose of this manuscript is to briefly review indications, management, and outcomes for the total artificial heart. Video operative techniques for device implantation are presented.

With advances in technology, the use of mechanical circulatory support devices for end stage heart failure has rapidly increased. The vast majority of ...

Transplantation of Pulmonary Valve Using a Mouse Model of Heterotopic Heart Transplantation

Tissue engineered heart valves, especially decellularized valves, are starting to gain momentum in clinical use of reconstructive surgery with mixed results. However, the cellular and molecular mechanisms of the neotissue development, valve thickening, and stenosis development are not researched extensively. To answer the above questions, we developed a murine heterotopic heart valve transplantation model. A heart valve was harvested from a valve donor mouse and transplanted to a heart donor mouse. The heart with a new valve was transplanted heterotopically to a recipient mouse. The transplanted heart showed its own heartbeat, independent of the recipient&#8217;s heartbeat. The blood flow was quantified using a high frequency ultrasound system with a pulsed wave Doppler. The flow through the implanted pulmonary valve showed forward flow with minimal regurgitation and the peak flow was close to 100 mm/sec. This murine model of heart valve transplantation is highly versatile, so it can be modified and adapted to provide different hemodynamic environments and/or can be used with various transgenic mice to study neotissue development in a tissue engineered heart valve.

In order to understand the cellular and molecular mechanisms underlying neotissue formation and stenosis development in tissue engineered heart valves, a murine model of heterotopic heart valve transplantation was developed. A pulmonary heart valve was transplanted to recipient using the heterotopic heart transplantation technique.

Tissue engineered heart valves, especially decellularized valves, are starting to gain momentum in clinical use of reconstructive surgery with mixed ...

Rat Heterotopic Abdominal Heart/Single-lung Transplantation in a Volume-loaded Configuration

Herein, we describe a novel technique for heterotopic abdominal heart-lung transplantation (HAHLT) in rats. The configuration of the transplant graft involves anastomosis of donor inferior vena cava (IVC) to recipient IVC, and donor ascending aorta (Ao) to recipient abdominal Ao. The right upper and middle lung lobes are preserved and function as conduits for blood flow from right heart to left heart.
There are several advantages to using this technique, and it lends itself to a broad range of applications. Because the graft is transplanted in a configuration that allows for dyamic volume-loading, cardiac function may be directly assessed in vivo. The use of pressure-volume conductance catheters permits characterization of load-dependent and load-independent hemodynamic parameters. The graft may be converted to a loaded configuration by applying a clamp to the recipient&#8217;s infra-hepatic IVC. We describe modified surgical techniques for both donor and recipient operations, and an ideal myocardial protection strategy. Depending on the experimental aim, this model may be adapted for use in both acute and chronic studies of graft function, immunologic status, and variable ventricular loading conditions. The conducting airways to the transplanted lung are preserved, and allow for acute lung re-ventilation. This facilitates analysis of the effects of the mixed venous and arterial blood providing coronary perfusion to the graft.
A limitation of this model is its technical complexity. There is a significant learning curve for new operators, who should ideally be mentored in the technique. A surgical training background is advantageous for those wishing to apply this model. Despite its complexity, we aim to present the model in a clear and easily applicable format. Because of the physiologic similarity of this model to orthotopic transplantation, and its broad range of study applications, the effort invested in learning the technique is likely to be worthwhile.

We describe a novel technique for heterotopic abdominal heart-lung transplantation (HAHLT) in rats. The transplant configuration results in a partially loaded graft circulation, allowing direct functional assessment. This model may be employed for acute or chronic studies of function and immunologic status of the transplanted graft.

Herein, we describe a novel technique for heterotopic abdominal heart-lung transplantation (HAHLT) in rats. The configuration of the transplant graft ...

Heterotopic Cervical Heart Transplantation in Mice

The heterotopic cervical heart transplantation in mice is a valuable tool in transplant and cardiovascular research. The cuff technique greatly simplifies this model by avoiding challenging suture anastomoses of small vessels thereby reducing warm ischemia time. In comparison to abdominal graft implantation the cervical model is less invasive and the implanted graft is easily accessible for further follow-up examinations. Anastomoses are performed by pulling the ascending aorta of the graft over the cuff with the recipient&#8217;s common carotid artery and by pulling the main pulmonary artery over the cuff with the external jugular vein. Selection of appropriate cuff size and complete mobilization of the vessels are important for successful revascularization. Ischemia-reperfusion (I/R) injury can be minimized by perfusing the graft with a cardioplegic solution and by hypothermia. In this article, we provide technical details for a simplified and improved cuff technique, which should allow surgeons with basic microsurgical skills to perform the procedure with a high success rate.

The cuff technique shortens and facilitates the model of heterotopic cervical heart transplantation in mice by avoiding technically challenging suture anastomoses of small vessels. The technical details shown in this video paper should allow researches to establish this model in their laboratories.

The heterotopic cervical heart transplantation in mice is a valuable tool in transplant and cardiovascular research. The cuff technique greatly simplifies ...

Use of Two Intracorporeal Ventricular Assist Devices As a Total Artificial Heart

Mechanical circulatory support (MCS) has been introduced as a viable alternative to heart transplantation primarily through the use of intracorporeal ventricular assist devices (VADs) for support of the left ventricle. However, certain clinical scenarios warrant biventricular mechanical support. One strategy for some patients is the excision of both ventricles and the implantation of two VAD pumps as a total artificial heart (TAH). This has recently been made possible by the improvements in device design and the small profile of centrifugal devices. This TAH approach remains experimental with many important challenges such as the device settings to balance the right and left circulation, the orientation of the devices and the outflow graft with their influence on hemolysis and stability, and the outcome of chronic support using such an orientation. This protocol aims to provide a reproducible approach for total artificial heart replacement with two intracorporeal centrifugal VADs in a cow model.

Here, we present a protocol using two centrifugal pumps as a total artificial heart replacement.

Mechanical circulatory support (MCS) has been introduced as a viable alternative to heart transplantation primarily through the use of intracorporeal ...

Implantation of hiPSC-derived Cardiac-muscle Patches after Myocardial Injury in a Guinea Pig Model

Due to the limited regeneration capacity of the heart in adult mammals, myocardial infarction results in an irreversible loss of cardiomyocytes. This loss of relevant amounts of heart muscle mass can lead to the heart failure. Besides heart transplantation, there is no curative treatment option for the end-stage heart failure. In times of organ donor shortage, organ independent treatment modalities are needed. Left-ventricular assist devices are a promising therapy option, however, especially as destination therapy, limited by its side-effects like stroke, infections and bleedings. In recent years, several cardiac repair strategies including stem cell injection, cardiac progenitors or myocardial tissue engineering have been investigated. Recent improvements in cell biology allow for the differentiation of large amounts of cardiomyocytes derived from human induced pluripotent stem cells (iPSC). One of the cardiac repair strategies currently under evaluation is to transplant artificial heart tissue. Engineered heart tissue (EHT) is a three-dimensional in vitro created cardiomyocyte network, with functional properties of native heart tissue. We have created EHT-patches from hiPSC derived cardiomyocytes. Here we present a protocol for the induction of left ventricular myocardial cryoinjury in a guinea pig, followed by implantation of hiPSC derived EHT on the left ventricular wall.

Here we present a protocol for the induction of left ventricular cryoinjury followed by the implantation of a cardiac muscle patch, derived from human iPS-cell cardiomyocytes in a guinea pig model.

Due to the limited regeneration capacity of the heart in adult mammals, myocardial infarction results in an irreversible loss of cardiomyocytes. This loss ...

A Pre-Clinical Porcine Model of Orthotopic Heart Transplantation

Fifty-years following the first successful report, cardiac transplantation remains the gold-standard treatment for eligible patients with advanced heart failure. Multiple small-animal models of heart transplantation have been used to study the acute and long-term effects of novel therapies. However, few are tested and demonstrated success in clinical trials. It is of critical importance to evaluate new therapies in a clinically relevant large-animal model for efficient and reliable translation of basic studies&#39;&#160;findings. Here, we describe a pre-clinical large-animal (porcine) model of orthotopic heart transplantation that has been firmly established and previously used to investigate novel cardioprotective strategies. This procedure focuses on acute ischemia-reperfusion injury and is a reliable method to investigate novel interventions which have been tested and validated in smaller experimental models, such as the murine model. We demonstrate its usefulness in assessing cardiac performance during the early post-transplantation period and other potential possibilities enabled by the model.

Here, we describe a pre-clinical large-animal (porcine) model of orthotopic heart transplantation that has been firmly established and utilized to investigate novel cardioprotective strategies.

Fifty-years following the first successful report, cardiac transplantation remains the gold-standard treatment for eligible patients with advanced heart ...

A Simplified Model for Heterotopic Heart Valve Transplantation in Rodents

There is an urgent clinical need for heart valve replacements that can grow in children. Heart valve transplantation is proposed as a new type of transplant with the potential to deliver durable heart valves capable of somatic growth with no requirement for anticoagulation. However, the immunobiology of heart valve transplants remains unexplored, highlighting the need for animal models to study this new type of transplant. Previous rat models for heterotopic aortic valve transplantation into the abdominal aorta have been described, though they are technically challenging and costly. For addressing this challenge, a renal subcapsular transplant model was developed in rodents as a practical and more straightforward method for studying heart valve transplant immunobiology. In this model, a single aortic valve leaflet is harvested and inserted into the renal subcapsular space. The kidney is easily accessible, and the transplanted tissue is securely contained in a subcapsular space that is well vascularized and can accommodate a variety of tissue sizes. Furthermore, because a single rat can provide three donor aortic leaflets and a single kidney can provide multiple sites for transplanted tissue, fewer rats are required for a given study. Here, the transplantation technique is described, providing a significant step forward in studying the transplant immunology of heart valve transplantation.

This protocol describes a simple and efficient method for the transplantation of aortic valve leaflets under the renal capsule to allow for the study of alloreactivity of heart valves.

There is an urgent clinical need for heart valve replacements that can grow in children. Heart valve transplantation is proposed as a new type of ...

A Porcine Heterotopic Heart Transplantation Protocol for Delivery of Therapeutics to a Cardiac Allograft

Cardiac transplantation is the gold standard treatment for end-stage heart failure. However, it remains limited by the number of available donor hearts and complications such as primary graft dysfunction and graft rejection. The recent clinical use of an ex vivo perfusion device in cardiac transplantation introduces a unique opportunity for treating cardiac allografts with therapeutic interventions to improve function and avoid deleterious recipient responses. Establishing a translational, large-animal model for therapeutic delivery to the entire allograft is essential for testing novel therapeutic approaches in cardiac transplantation. The porcine, heterotopic heart transplantation model in the intraabdominal position serves as an excellent model for assessing the effects of novel interventions and the immunopathology of graft rejection. This model additionally offers long-term survival for the pig, given that the graft is not required to maintain the recipient's circulation. The aim of this protocol is to provide a reproducible and robust approach for achieving ex vivo delivery of a therapeutic to the entire cardiac allograft prior to transplantation and provide technical details to perform a survival heterotopic transplant of the ex vivo perfused heart.

We present a protocol for utilizing a normothermic ex vivo sanguinous perfusion system for the delivery of therapeutics to an entire cardiac allograft in a porcine heterotopic heart transplant model.

Cardiac transplantation is the gold standard treatment for end-stage heart failure. However, it remains limited by the number of available donor hearts ...