HVAD Decommission in a Failing Mustard: Making Virtue out of Necessity

Abstract

Introduction Ventricular assist device (VAD) for systemic right ventricular failure (SRVF) in transposition of the great arteries (TGA) patients has proven useful to reduce transpulmonary gradient (TPG) and bridge-to-transplantation. Tricuspid valve replacement (TVR) at the time of implant to address severe tricuspid regurgitation (TR) may be beneficial to achieve optimal unloading of the systemic right ventricle (SRV). We report successful decommissioning of a SRV VAD following device thrombosis in a patient who underwent TVR at VAD implant. Case Report A 37-year-old man who underwent a Mustard procedure for TGA at 10 months of age presented with acute heart failure, triggered by leg cellulitis and pulmonary embolism. He was found to have a severely impaired SRV, severe TR and a dilated and moderately impaired subpulmonic left ventricle (LV). Despite medical management and anticoagulation, he worsened requiring admission to the ICU for inotropic support. A right heart catheter (RHC) showed a mean pulmonary artery (PA) pressure of 48 mmHg and TPG of 15 mmHg, therefore ineligible for heart transplant. He underwent successful HeartWare-VAD implantation into his failing SRV with concomitant systemic TVR. His post-operative course was uneventful and he was discharged after 25 days. After six months, his TPG came down to 4 mmHg and he was listed for heart transplantation. He remained stable and free from VAD complications until he presented with thrombosis of the outflow graft after 27 months. Anticoagulation with bivalirudin was started without success and persistent reduced VAD flow of Summary VAD implantation is a feasible strategy for those with SRVF. Concomitant TVR to address severe TR may have additional benefit and in this particular case, likely to have contributed to successful VAD decommissioning following device thrombosis.