A modified LVAD technique to augment caval and pulmonary arterial blood flow in the "failing Fontan" circulation.

BACKGROUND: There are minimal circulatory support options for patients with a failing Fontan. The Heartmate II (HMII) left ventricular assist device (Thoratec, Bedford, MA) in its packaged state cannot augment caval/pulmonary arterial blood flow. AIM: We hypothesized that a modified HMII pump could augment caval and pulmonary arterial blood flow. METHODS: A bifurcated ringed Gore-Tex graft (W. L. Gore & Associates, Flagstaff, AZ) was sewn to the HMII inflow, and the outflow graft transected and tapered from 16 mm to 8 mm in diameter. In three sheep, the inflow and outflow grafts were anastomosed end-to-side to both cava and the pulmonary artery. RESULTS: Following baseline measurements, the pump speed was increased to 8000 revolutions per minute (RPMs). Compared to baseline, at 8000 RPMs, there were no significant differences in mean arterial, central venous, or pulmonary arterial pressure. However, there was a significant decrease in right ventricular diastolic diameter (3.1 ± 0.1 vs. 1.8 ± 0.2 cm, R = 0.6, p = 0.02) and similarly a decrease in pulmonary arterial pulse pressure (8.5 ± 2.1 vs. 2.1 ± 2.9 mmHg, p = 0.01). As pump speed increased, there was a corresponding increase in pump flow and power, with a decrease in pulsatility index. CONCLUSIONS: These findings suggest that the HMII may be modified to provide caval/pulmonary circulatory support for the failing Fontan circulation.

Transfusion of cell saver salvaged blood in neonates and infants undergoing open heart surgery significantly reduces RBC and coagulant product transfusions and donor exposures: results of a prospective, randomized, clinical trial.

OBJECTIVE: To evaluate whether transfusion of cell saver salvaged, stored at the bedside for up to 24 hrs, would decrease the number of postoperative allogeneic RBC transfusions and donor exposures, and possibly improve clinical outcomes. DESIGN: Prospective, randomized, controlled, clinical trial. SETTING: Pediatric cardiac intensive care unit. PATIENTS: Infants weighing less than 20 kg (n = 106) presenting for cardiac surgery with cardiopulmonary bypass. INTERVENTIONS: Subjects were randomized to a cell saver transfusion group where cell saver blood was available for transfusion up to 24 hrs after collection, or to a control group. Cell saver subjects received cell saver blood for volume replacement and/or RBC transfusions. Control subjects received crystalloid or albumin for volume replacement and RBCs for anemia. Blood product transfusions, donor exposures, and clinical outcomes were compared between groups. MEASUREMENTS AND MAIN RESULTS: Children randomized to the cell saver group had significantly fewer RBC transfusions (cell saver: 0.19 ± 0.44 vs. control: 0.75 ± 1.2; p = 0.003) and coagulant product transfusions in the first 48 hrs post-op (cell saver: 0.09 ± 0.45 vs. control: 0.62 ± 1.4; p = 0.013), and significantly fewer donor exposures (cell saver: 0.60 ± 1.4 vs. control: 2.3 ± 4.8; p = 0.019). This difference persisted over the first week post-op, but did not reach statistical significance (cell saver: 0.64 ± 1.24 vs. control: 1.1 ± 1.4; p = 0.07). There were no significant clinical outcome differences. CONCLUSION: Cell saver blood can be safely stored at the bedside for immediate transfusion for 24 hrs after collection. Administration of cell saver blood significantly reduces the number of RBC and coagulant product transfusions and donor exposures in the immediate postoperative period. Reduction of blood product transfusions has the potential to reduce transfusion-associated complications and decrease postoperative morbidity. Larger studies are needed to determine whether this transfusion strategy will improve clinical outcomes.