Prolonged But Successful Weaning from Left Ventricular Assist Device After Cardiac Decompensation due to Late-Recognized Coarctation of the Aorta in a Toddler

A 2-year-old boy was presented with late-recognized coarctation of the aorta and pulmonary hypertension due to left ventricular failure. The coarctation was corrected at the day of admission with a good postoperative result. However, weaning from the respirator failed despite multiple drug support due to left ventricular failure. Consequently, a left ventricular assist device (LVAD) was implanted 22 days later. The further course was complicated by systemic hypertension and ongoing pulmonary hypertension requiring extensive antihypertensive therapy. Thefirst attempt to wean from LVAD failed and the left ventricle was left completely unloaded for additional 4 weeks. The second weaning attempt, using a very smooth weaning protocol, led to a recovered left ventricle and facilitated the removal of the assist device after a total of 120 days. The patient was discharged with normal cardiac function, but he still requires antihypertensive therapy. We believe that the slow reduction of the LVAD support was the key measure that leads to the successful weaning of the patient, thereby avoiding heart transplantation. ASAIO Journal 2008; 54:548‐550. Case Presentation A 2-year-old boy (body weight 12.5 kg, height 88 cm) was presented in the outpatient department by his parents due to respiratory problems. The patient had been well until 2 weeks ago. The boy was in reduced condition with elevated body temperature, tachypnea, rales, a systolic murmur, absence of femoral pulses and a pronounced cardiac hump. Chest x-ray showed cardiomegaly. Echocardiography revealed coarctation of the aorta and pulmonary hypertension due to left ventricular failure. The coarctation was corrected the day of admission by end-to-end anastomosis. Echocardiography showed a good postoperative result. Weaning from the respirator failed, despite support with inotropics (dopamine, noradrenaline), Casensitizer (levosimendan), diuretics (furosemide, nesiritide, and spironolactone) and afterload reduction using nitroglycerine and clonidin. Despite extended therapy, switching from catecholamines to beta-blockers (esmolol and atenolol) did not succeed and angiotensin converting enzyme (ACE) inhibitors (lisinopril) was introduced. Extubation attempts over a 3 weeks-period failed due to left ventricular failure. Consequently, a left ventricular assist device (LVAD) (ExcorPediatric, 25 ml ventricle, Berlin Heart, Germany) was implanted on day 22 after admission.