Carotid Endarterectomy Prior to Ventricular Assist Device Placement in a Patient with Cardiogenic Shock

Abstract

<h3>Introduction</h3> Atherosclerotic disease in the cervical vessels may be a contraindication for implantation of left ventricular assist devices (LVADs). The occurrence of ischemic stroke represents an obstacle to rehabilitation, and its incidence seems to be higher in this population. Carotid endarterectomy (CEA) is a preferable surgical treatment in patients with high bleeding risk. This case report suggests that CEA followed by implantation of LVADs can be feasible. <h3>Case Report</h3> A 55 y/o woman with advanced heart failure (AHF) due to ischemic cardiomyopathy was admitted in the hospital with cardiogenic shock and started treatment. She evolved with three failures in weaning the inotropic agent, and was evaluated for heart transplantation (HT). She had a panel-reactive antibody with 79% class II and a critical right carotid artery stenosis was evidenced. She had preserved right ventricular function; consequently, implantation of LVAD was an option. However, she presented an episode of hypotension, dysarthria and left hemiparesis in the preoperative period that reversed after intra-aortic balloon (IAB) placement and hemodynamic stabilization. Computed tomography angiography showed right internal carotid artery sub-occlusion and transcranial Doppler ultrasound with the cerebral flow within normal range despite hemodynamic support. CEA of both the right internal and common carotid artery was performed. The patient tolerated the procedure despite using inotropic and IAB, recovering with no neurological deficit. Heart Mate III was implanted after 15 days. The patient evolved well and is currently in an outpatient follow-up for 1 year. <h3>Summary</h3> The appropriate interval between CEA and LVAD implantation is not well established; however, we assume that early intervention might reduce a cerebral ischemic event's risk. If a stroke occurred during LVAD implantation, rehabilitation would be expensive and complex, and future HT might be contraindicated. The team agreed that the most appropriate technique, in this case, was CEA instead of percutaneous stent implantation as the second technique would require dual antiplatelet therapy. With the increasing number of patients with AHF undergoing LVAD, comorbidities such as severe cerebrovascular disease may occur. This case report suggests that CEA followed by LVAD insertion can be safe and feasible even in cardiogenic shock.