Jumping and Pumping: Balancing Physical Activity and Anticoagulation in Ventricular Assist Devices

Abstract

<h3>Introduction</h3> Pre-transplant rehabilitation, which includes physical activity, is critical for optimal outcomes in heart transplantation. Patients supported on ventricular assist devices (VAD) are on anticoagulation to limit adverse vascular events and ensure VAD function. However, anticoagulation is not without risk. We present the case of traumatic arthropathy related to physical activity in an anticoagulated VAD patient. <h3>Case Report</h3> A 27-month-old with left ventricular noncompaction, restrictive cardiomyopathy, developmental delay, and sensory processing disorder presented in heart failure. Despite inotropic support, he continued to decline and underwent placement of a 15-mL Berlin Heart EXCOR VAD as a bridge to transplant. He recovered well from the procedure and was maintained on bivalirudin and aspirin for anticoagulation. Direct thrombin inhibition (DTI) measurements were within goal (80-100 secs). He was able to participate in structured physical and occupational rehabilitation and continue physical activity outside of scheduled sessions. On VAD day 161 he developed irritability with resistance to flexion and increased pain at the right hip, shortly after jumping on a trampoline provided by the family. Ultrasonography demonstrated an effusion without soft tissue abscess or inflammation. An initial C-reactive protein was normal (0.9 mg/dl), increased to 17.7 mg/dl, but then normalized within 24 hours. He had a normal white blood cell (WBC) count and remained afebrile and hemodynamically stable. A right hip aspiration demonstrated an elevated WBC (152 K/microliter) with a neutrophil predominance (72%) and a red blood cell count of 14 K/microliter. Due to concern for septic arthritis he was started on broad spectrum antibiotics and had a right hip arthrotomy. As the gram stain and hip cultures remained negative for 72 hours, antibiotics were stopped. Following rest and pain control he was able bear weight and successfully underwent heart transplant. <h3>Summary</h3> Musculoskeletal symptoms in VAD patients require careful evaluation as they may represent a variety of pathologies. It is important for clinicians to balance anticoagulation strategies with structured and unstructured rehabilitative endeavors for patients on VAD support, recognizing that local trauma related to physical activity may be magnified by anticoagulation.