Urgent implantation of the Berlin Heart Excor biventricular assist device as a total artificial heart in a patient with single ventricle circulation

Background: The management of patients presenting with heart failure after total cavopulmonary connection remains an ongoing challenge.

Introduction: A 19-year-old boy with single ventricle anatomy presented to our department with failing Fontan circulation and secondary end-stage cardiorespiratory failure. Most recently he presented to our center with intractable cardiac failure along with massive dilation of the system ventricle in NYHA status IV. The patient was reported to Eurotransplant as a high-urgency transplant candidate. Despite high dose inotropic support and maximal therapy of cardiac failure he developed acute cardiorespiratory failure with signs of cerebral malperfusion according to near-infrared spectroscopy. Due to massive adhesions in the mediastinum it was exceedingly difficult to achieve an access to cardiac structures. Besides rigidity of the tissue, extensive bleeding ensued because of dense collateral vessel formation. However, after complete exposure of all cardiac structures the implantation of a biventricular assist device seemed impossible due to the massive dilatation of the heart leading to extremely limited space in the mediastinum. We decided for the explantation of the heart and the implantation of the Berlin Heart biventricular assist device (Berlin Heart AG, Berlin, Germany) as a total artificial heart. After explantatation of the heart the left atrial remnant and the Fontan pathway including superior vena cavan and the right pulmonary artery had to be reconstructed and the native aorta downsized to enable implantation of the device cannula. Both the aortic and pulmonary artery cannula of the assist device had to be extended using prostetic vessel grafts.

Discussion: Our strategy enabled our patient's survival until the performance of heart transplantation. To our knowledge this is the first report of the implantation of the Berlin Heart Excor biventricular assist device as a total artificial heart enabling a “bridge to transplant” strategy in a patient with single ventricle circulation.