Managing Infectious Complications in the Immunocompromised Stage D Heart Failure Patient: A Case of Left Ventricular Assist Device Placement in a Patient with Chronic Lymphocytic Leukemia

Abstract

<h3>Introduction</h3> Little is known about placement and management of a durable left ventricular assist device (LVAD) in patients with chronic hematologic malignancies. We describe the inherent challenges and complications of a case of LVAD implantation in a patient with chronic lymphocytic leukemia (CLL). <h3>Case Report</h3> A 77-year-old man with CLL, stage D heart failure and placement of a HeartMate 3 LVAD one month prior returned to the hospital after a recent hospitalization to the intensive care unit (ICU) for respiratory failure and sepsis secondary to an empyema. The patient returned with dyspnea, altered mentation, and was again admitted to the ICU for septic shock and respiratory failure requiring mechanical ventilation. The patient's presenting white blood cell count was 77,500 K/uL and concerning for infectious etiology though confounded by the patient's known CLL. His presenting heart rate was 103 beats per minute and blood pressure was 70/50 mmHg with a respiratory rate of 17. The patient was found to be septic from multiple sources. Blood cultures were positive for <i>Klebsiella Pneumoniae</i>, tracheal aspirate was positive for <i>Burkholderia Cepacia</i> and urine culture was positive for <i>Citrobacter Freundii</i> and <i>Candida Albicans</i>. The infections were treated successfully with ceftazidime and fluconazole for 2 weeks with a prolonged duration determined by clinical response given chronic leukocytosis in the setting of CLL. <h3>Summary</h3> We present a patient with known CLL who experienced multiple ICU admissions within 3 months of LVAD placement and required treatment for distinct infectious sources as a cause of the critical illness during each admission. This case demonstrates the immunocompromised state of chronic hematologic malignancies and the necessity to maintain a high suspicion for infection despite chronic leukocytosis confounding workup in the post-operative course. We emphasize the need to consider these increased risks when determining candidacy for durable devices and to discuss these risks with patients who have chronic hematologic malignancies and stage D heart failure considering LVAD implantation.