 Hello Texas Heart Institute. My name is Tiffany Robb. It is a privilege to be here representing my profusion team and to be speaking amongst this special conference honoring women leading with the heart. Maya Angelou said it herself, the desire to reach for the stars is ambitious. The desire to reach hearts is wise. We can accomplish so much together by empowering and motivating others. By way of a little professional background I have accumulated nine years of experience in pediatric perfusion first at the Mayo Clinic in Minnesota followed by Children's Hospital Los Angeles and now at Dell Children's Medical Center in Austin, Texas. In this time I have witnessed the palliative struggles that single ventricle patients endure and therefore wanted to share this case report on a novel method to safely de-air a heart-ware system in a single ventricle patient by utilizing ECMO in a modified bypass circuit. As you may already know single ventricle congenital heart disease is a rare high-risk complex cardiac disorder where one lower chamber or ventricle does not develop. Single ventricle defects often require stage reconstructive procedures ultimately resulting in a fontan circulation. This surgical palliation is meant to improve passive blood flow to the lungs while further offloading the systemic ventricle. Despite medical advancements, long-term complications, and the potential developments of heart failure challenge the overall survivability of this patient population. In one study nearly half of the patient sample size with an extracardia conduit suffered an adverse event within 15 years. Given a worldwide shortage of transplantable organs, mechanical circulatory support represents an alternative treatment option that has begun to be evaluated. Outcomes for all children receiving a VAD as a bridge modality fare significantly better when compared to long-term ECMO. In this case report we describe a 31 kilogram 12-year old female with heterotaxi syndrome and failing single ventricle physiology. The patient encountered bilateral glen and fenestrated fontan palliations at one in three years of age respectively. She presented to us with failing fontan physiology and severe AV valve regurgitation. While hospitalized, the patient suffered from a sudden event of rapid atrial tachycardia that degenerated into pulseless ventricular tachycardia. Chest compressions were initiated and continued for a total of 110 minutes until she was cannulated and placed on venous arterial ECMO through the right neck. The patient remains on VA ECMO for six days at a flow rate of approximately 80 milliliters per kilogram per minute. A failure to wean from VA ECMO is demonstrated by elevated fontan pressures. Because the cable pulmonary connection can be a challenging circulation to support with ECMO over the long term, it was considered beneficial for short-term resuscitative support in this case. Therefore, the decision was made to place a heart-ware HVAD as a durable option in anticipation of bridging to heart transplantation. The patient was ultimately listed as status 1A candidate for heart transplant. I want to take a moment here to refresh our memories on the heart-ware ventricular assist system. It is a small, continuous flow pump intended for implantation into the left ventricle and augmentation of cardiac output. The heart-ware has become a favorable selection for pediatrics owing to its integrated short inflow cannula, complete intrapericardial implantation, and percutaneous driveline, as well as capacity for outpatient management. The first report of a successful long-term HVAD in a patient with fontan circulation was published in 2014 with credit to Children's Hospital of Wisconsin. With the original plan to implant the heart-ware on full bypass, an appropriately sized circuit was set up with a physiologic isoelectric blood prime. The patient was transported to the operating room on full ECMO support. Once in the chest, it became apparent from the patient's anatomy and reoperative adhesions that she would present a greater challenge for bypass cannulation. Therefore, the safer alternative was to implant the HVAD on ECMO with a modification of the bypass circuit to vent air from the heart in a controlled fashion. Harry presents an original technique for the implantation of a durable VAD to the left, which combines ECMO in a modified cardiopulmonary bypass circuit. In preparation for the surgical implantation of the HVAD and exposure to a modified bypass circuit, a 300 unit per kilogram heparin loading dose was administered with an appropriate ACT result of 497 seconds. The HVAD pump was cordoned to the patient's common atrium, and a short outflow graft was a nasty most to the ascending aorta with a side-biter clamp. Meanwhile, a modified extracorporeal circuit was assembled for the dearing phase of the operation. A volume resuscitation line noted by the red dash line here was attached from the arterial recirculation line post oxygenator via a high flow stopcock to the venous limb of the ECMO arterial venous bridge. Let's just be reminded that full ECMO support was maintained throughout this procedure. To begin dearing the heart, the surgeon inserted a needle vent into the ascending aorta near the HVAD outflow graft. This created a pathway for purging any gaseous emboli entrained in the ascending aorta through a designated vent to the bypass reservoir. This blood and air mixture was actively pumped into the top of the bypass reservoir at a rate of 150 milliliters per minute or less than 10% of the ECMO flow rate. This blood volume was then filtered at a similar rate through the oxygen oxygenator in arterial filter of the bypass circuit before reinfusion into the venous limb of the ECMO circuit. Venting and volume replacement were titrated to maintain the human dynamics stability of the patient during sustained VA ECMO supports. The patient was weaned from ECMO as the HVAD pump was gradually initiated. Once dearing was deemed a success, the erratic root vents was removed. Upon establishing stability of the VAD ECMO cannulas were also withdrawn. After a whopping 490 days on heart wear HVAD support, the patient underwent successful heart transplantation. As previously described, pediatric VAD support for failing single ventricle physiology presents its many challenges despite significant advancements and superiority to conventional ECMO. The purpose of this case report is to share a controlled method for venting the heart when transitioning between circulatory support devices in a complex patient with very few operative alternatives. Therefore, unveiling new techniques for clinical reference and the safe management of complex patients will facilitate the potential for improved outcomes and the likelihood of bridging to other therapies. Thank you very much for your time.