Berlin Heart ECMO

So, I wanted to talk about this crazy case that happened on my first week at Vandy, because this is an awesome story of the versatility of Perfusion!
We had a patient that presented with AVcanal defect, with severe mitral and tricuspid regurgitation. This patient came in for AV canal repair, mitral and tricuspid repair. The patient was not doing well after coming off bypass and went on ECMO support. After a few days on ECMO the patient still suffered from severe MR so the patient was brought back to the OR, they were unable to repair the leaky valve, and required an new mitral valve. (FYI they do not make porcine valves for peds patients so it has to be a mechanical valve, and just think how many times you would have to have surgery again to replace the valve as the patient grows bigger. So putting a mechanical valve is a rarity and is avoided at almost all costs).

The first valve was inserted the patient still had issues post bypass and ECMO was continued. They determined that there was an annular leak around the valve and required further repair. Patient was brought back to the OR for repair. Again, issues remained post bypass, and ECMO was still continued. Then issues began to arise with the mechanical valve, it kept getting stuck open, so the patient had wide open MR. The patient was brought back to the OR again for another valve replacement (this was my first case experience at Vandy and was called back to TN from my turkey day vacation in IN to see this case). The patient continued to have arterial saturation issues and ECMO was continued. Finally, the Berlin Heart implantation was decided for this patient. (Also, FYI the Berlin heart is not FDA approved so to use it on a patient requires FDA compassionate use, and they must approve of this before the device can be implanted).

FDA approval comes, and we move forward with implantation. The LVAD was successfully implanted, and about 20 minutes later the patient began to go into right heart failure and the use of an RVAD was required. RVAD implantation was successful, and then the patient sats began to deteriorate again. The surgeon says we have to go back on ECMO, but there is one major problem, this baby is only a few months old, has been put on bypass over 4 different times, has our current bypass cannula in to transfuse volume, these massive inflow and outflow VAD cannula that seriously swallow they entire patients chest cavity, the surgeon has nowhere else to cannulate for ECMO support. After discussion with the Berlin Heart rep and her making several calls to other perfusion teams throughout the US, and determining that the pressure drop across the Quadrox-iD pedi oxygenator was low enough to not hinder the VAD support. We decided to insert the oxygenator into the inflow cannula of the LVAD for ECMO support. You wouldn't think it but it was successful, the patient did well on this type of "ECMO" support.

Unfortunately, the ending to this story is not a happy one, but it really shows that we as Perfusionists have to think on our feet about helping the surgeon keep a patient alive, and believe it or not, know your IFU's and have them available because without those, this wouldn't have been a possible option.

Sonya