P60: A decade on LVAD support

Abstract

Objective: The use of left ventricular assist devices (LVADs) to support patients with end-stage heart failure (HF) has been progressively adopted over the past 2 decades, with long-term outcomes reporting 50% survival at 5 years, particularly related to development of complications on support. However, there is a paucity of information related to survival beyond 10 years. Herein, we report the case of an 85-year-old man with end stage ischemic cardiomyopathy with an 11-year continuous LVAD support as destination therapy (DT). Case Report: An 85-year-old man transferred from an outside hospital, presented to the emergency department due to concerns for a driveline infection. The patient has an 11-year-old history of HeartMate2-LVAD support as destination therapy (DT) due to an end-stage ischemic cardiomyopathy. Patient has undergone automatic implantable cardioverter defibrillator secondary to atrial fibrillation, as well as a primary coronary artery disease requiring multiple percutaneous coronary interventions, in addition to an aortic and mitral valve repair. He was last seen 2 years prior to this consultation for an external LVAD drive line replacement and a chronic infection which is under oral Cefalexin management (500mg/day). Additionally, the patient continues anticoagulation therapy (aspirin 81 mg/day; warfarin 10 mg/day) with a target INR of 2.5, and has not experienced any thromboembolic or hemorrhagic complications. On clinical evaluation, driveline insertion showed a non-tender, mild erythematous aspect, with no exudation. A CT scan of the thorax and abdomen was performed, demonstrating no involvement of deep tissues. Results: Initial echocardiographic evaluation showed a left ventricular ejection fraction of 20%, moderate-to-severely reduced right ventricular systolic function, a right atrial pressure of 15 mmHg, moderate tricuspid regurgitation, and a left ventricular end diastolic diameter of 6.5 cm. Upon physical examination the patient was warm and well-perfused with an euvolemic appearance. The LVAD settings remain steady at 9400 rpm and a 5.0 L/min flow. The driveline exit site elicited no pain at palpation, with mild erythema. Due to a sustained hemodynamic function in perspective to the patient’s end-stage heart failure, 500 mg of cefalexin/daily was continued and patient was discharged with no complications and continued monitorization. Conclusion: To the authors’ knowledge, this case represents one of longest reports of LVAD support as DT. The continuing improvement of LVAD management has led to the safe and feasible application of long-term cardiac function support as DT for patients deemed not transplant candidates. As our elderly population expands, and over 80% of patients with heart failure are older than 65 years, the role LVAD for long-term support will become more relevant, and this case reveals that safe LVAD support is possible beyond 10 years.