Cardiac Transplantation After HYBRID+VAD Support in Patients With HLHS: Technical Considerations and Outcomes.

BACKGROUND

High-risk patients with hypoplastic left heart syndrome can be supported with combined Hybrid Stage 1 (arterial duct stenting, bilateral pulmonary artery banding, and atrial septectomy if needed) and ventricular assist device (VAD) insertion (HYBRID+VAD) as a bridge to transplantation. Concerns have been raised about the challenges and complexity of the subsequent cardiac transplantation. The purpose of this analysis was to review the investigators' experience with 7 consecutive infants with functionally univentricular ductal-dependent systemic circulation who underwent cardiac transplantation after HYBRID+VAD.

METHODS

Ten consecutive high-risk neonates with functionally univentricular ductal-dependent systemic circulation and major cardiac risk factors were supported with HYRID+VAD, and 7 underwent subsequent cardiac transplantation. The characteristics and outcomes of cardiac transplantation for these 7 patients were reviewed.

RESULTS

The median length of VAD support was 154 days (range, 64-226 days). The median age at cardiac transplantation was 177 days (range, 84-250 days). Six of 7 transplants (85.7%) were ABO incompatible. All 7 patients successfully underwent transplantation with aortic arch reconstruction and simple pulmonary artery band removal and dilation. No patients underwent pulmonary artery augmentation at transplantation. Median (range) transplantation times in minutes were as follows: cardiopulmonary bypass time, 169 (139-208); cross-clamp time, 89 (56-116); antegrade cerebral perfusion time, 29 (24-39); and donor ischemic time, 212 (139-236). The minimum temperature was 20.4 °C (range, 19.6-22.8 °C). One patient had posttransplant vocal cord dysfunction and underwent gastrostomy tube insertion. The median posttransplant length of stay was 26 days (range, 8-43 days). No patients have undergone subsequent transcatheter or surgical interventions on their aorta or pulmonary arteries. All 7 patients are currently alive and well, with follow-up after transplantation of 3.9 years (range, 2.2-7.1 years).

CONCLUSIONS

Cardiac transplantation after HYBRID+VAD can be performed safely and effectively and results in excellent short-term and midterm outcomes.