Abstract
Introduction Cardiogenic shock requiring mechanical circulatory support as a bridge to recovery continues to pose challenges. For patients who are unable to be weaned off of temporary device support, durable assist devices are an option. Unfortunately, patients receiving durable biventricular ventricular assist devices (BiVADs) represent a critically ill population with high operative mortality and RVAD thrombosis rates. Case A 58 year-old male with hypertension underwent an elective laparoscopic hemicolectomy. Post-surgery, he developed chest pain. ECG showed an anterior STEMI and transthoracic echocardiogram revealed a new ejection fraction of 30% with anterolateral and lateral wall hypokinesis. Cardiac catheterization revealed a 100% occluded left anterior descending artery, which prompted percutaneous coronary intervention and intra-aortic balloon placement. Due to worsening hemodynamics, he required emergent central veno-arterial extracorporeal membrane oxygenation (VA ECMO) placement. Due to sustained ventricular fibrillation and biventricular dysfunction on VA ECMO, he underwent ECMO revision, with placement of temporary CentriMag BiVADs. After 60 days of inability to wean temporary biventricular support, durable Medtronic Heartware BiVADs were placed as bridge to transplant. One week after durable BiVAD placement, patient developed low flows on the RVAD and profound hypoxia. He was taken to operating room emergently, and was found to have RVAD thrombosis and an apical ventricular septal defect (VSD). The RVAD was replaced and the VSD was repaired. After 18-months on BiVAD support he had a successful orthotropic heart transplant and continues to do well post-transplant. Conclusion Our case demonstrates challenges associated with selecting appropriate mechanical circulatory support devices for adequate cardiovascular support and navigating potential device related complications. Frequent reassessment is necessary to impact positive outcomes in this critically ill patient population.
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