Bypassing the Ordinary: A Patient's Unique Journey to Reach His Destination

Abstract

<h3>Introduction</h3> Advanced heart failure therapies include an armamentarium of mechanical circulatory support (MCS). We present a case for which an array of mechanical support systems were utilized to save a patient. <h3>Case Report</h3> A 71-year old male with HTN, HLD, and smoking history presented with expressive aphasia due to an embolic CVA. Initial workup revealed an ejection fraction <20% with severe global hypokinesis on TEE, and an occluded distal left main and multi-vessel disease by left heart catheterization. Patient underwent a noncomplicated quadruple bypass surgery. Post-operative day #3, he suffered a ventricular fibrillation cardiac arrest and was promptly taken to the OR for emergency IABP insertion followed by central cannulation for VA-ECMO. Post-operative day #4, his pressor requirements increased and a TEE revealed an EF of 5% despite IABP and VA-ECMO support. He was taken back again to the OR for axillary Impella 5.0 implantation and decannulation of VA-ECMO. Over the next couple weeks, he was weaned from pressors, but developed fevers of unknown origin. A CT head revealed a new frontal lobe hematoma in addition to a subacute CVA. He remained neurologically intact, though unable to wean from ventilation. A tracheostomy and PEG tube were inserted. The patient was highly functioning prior to his presentation and wanted everything done including LVAD implantation. A midline sternotomy approach was not suitable due to recent CABG and emergent central cannulation of ECMO; therefore, he underwent Heartmate 3 LVAD implantation via left thoracotomy approach with descending aorta outflow graft cannulation (see Figure 1) as destination therapy. He was discharged to acute rehab post-operative day# 55 and is now home, with tracheostomy and PEG discontinued, and able to walk with limited assistance. <h3>Summary</h3> In cases necessitating various MCS modalities, a left thoracotomy approach with descending aorta outflow graft cannulation for LVAD may be a viable alternative to midline sternotomy.