Timing of LVAD Implantation: A Case Report

Division

West Florida

Hospital

Northside Hospital

Document Type

Case Report

Publication Date

8-2019

Keywords

left ventricular assist device, heart-assist devices

Disciplines

Cardiology | Cardiovascular Diseases | Equipment and Supplies | Surgical Procedures, Operative

Abstract

Optimal timing of left ventricular assist device (LVAD) implantation in critically ill patients remains uncertain. Multiple studies have demonstrated that implantation of LVADs in hemodynamically stable patients with preserved end-organ function leads to better outcomes. Although seemingly intuitive, this concept highlights the importance of patient selection and the optimal timing of LVAD implantation in critically ill patients. A 35 year-old gentleman with a past medical history of morbid obesity and alcohol abuse presented from an outside hospital. He was initially diagnosed with a cardiomyopathy eight years prior to admission, although demonstrated recovery of his left ventricular ejection fraction (LVEF) after guideline directed medical therapy. He subsequently stopped his medications five years prior to admission and had been doing well. He initially presented to the other institution with shortness of breath and progressive dyspnea on exertion. A cardiac catheterization was performed and demonstrated nonobstructive coronary artery disease. An echocardiogram demonstrated severe biventricular failure with an estimated LVEF of 10%, severe mitral regurgitation and an elevated RVSP of 40%. An Impella 3.5 was placed and the patient was aggressively diuresed. Despite ongoing management, the patient developed multi-organ failure with a peak total bilirubin of 65.5 mg/dL and a creatinine of 4.27 mg/dL. He was transferred to our institution for advanced therapy.

Given his morbid obesity and findings of progressively worsening multi-organ failure, immediate surgical intervention was deferred. With placement of an Impella 5 and continued aggressive medical management, he made daily improvement. Multiple selection committee discussions were held regarding the optimal timing of intervention on the previously healthy 35 year old gentleman. Temporary LVAD support with the Impella 5 was maintained for a total of 5 weeks while his respiratory, renal, liver and nutritional function were addressed. The patient was found with significant azotemia and anuria which ultimately improved with supportive medical care and continuous renal replacement therapy. Prior to LVAD implantation, CRRT was no longer required. A HeartMate 3 was ultimately implanted on day 42 of his hospitalization and the patient continued to make excellent progress in recovery. It is unclear what led to the patient's decline in cardiac function, although his morbid obesity, continued alcohol use and cessation of medical therapy likely all contributed. It Is impossible to determine whether earlier intervention would have changed his outcome. Regardless, this case highlights the importance of careful patient selection and multidisciplinary decision-making for timing of LVAD implantation.

Publisher or Conference

Journal of Cardiac Failure

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