Berlin cannulation with an outflow interposition graft-a versatile technique

The Berlin Heart EXCOR VAD is increasingly used to support more complex patients with heart failure. To accommodate variable arterial anatomy, a modified outflow with a long interposition graft connected to an "apical" cannula is an attractive alternative to the conventional, rigid "arterial" cannula.

We conducted a single-center retrospective review of consecutive patients who underwent Berlin cannulation using this novel technique between September 2020 and May 2025.

Fifty consecutive patients were identified. Median (range) age, weight, and body surface area at implantation were 0.7 (9 days-10.4) years, 7.8 (3.1-21.7) kg, and 0.4 (0.21-0.86) m², respectively. Underlying etiologies were congenital heart disease (26, 52%, of which 22 are single ventricle) and cardiomyopathy (24, 48%). Graft material was expanded polytetrafluoroethylene in 43 (86%) and Dacron in 7 (14%). Target outflow vessel was native aorta in 34 (68%), neoaorta in 11 (22%), and main pulmonary artery in 5 (10%). Favorable outcomes were achieved in 41 (82%): transplant for 30, ongoing support for 8, and explantation for myocardial recovery for 3, whereas 9 (18%) patients died. Significant hemolysis occurred in 7 (14%) patients, 4 of whom had Dacron grafts, 2 of whom required surgical reintervention. Subsequently, expanded polytetrafluoroethylene became the material of choice because of its smooth internal surface, which may reduce shear stress in the setting of high stroke volume from the EXCOR pump.

The long interposition graft technique offers versatility and flexibility to the VAD outflow. Selection of optimal graft material and size may need attention for improved outcomes.