Rapidly Progressive Left Ventricular Assist Device Outflow Graft Thrombosis Associated With COVID-19 Infection.

Abstract

HomeCirculation: Heart FailureVol. 14, No. 12Rapidly Progressive Left Ventricular Assist Device Outflow Graft Thrombosis Associated With COVID-19 Infection Free AccessCase ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessCase ReportPDF/EPUBRapidly Progressive Left Ventricular Assist Device Outflow Graft Thrombosis Associated With COVID-19 Infection Valmiki Maharaj, Marie Steiner, Brenden Boyle, Felipe Kazmirczak, Jeremy Markowitz, Tamas Alexy, Andrew Shaffer, Ranjit John, Cindy M. Martin, Rebecca Cogswell and Forum Kamdar Valmiki MaharajValmiki Maharaj https://orcid.org/0000-0003-0442-0021 Division of Cardiology, Department of Medicine (V.M., B.B., F. Kazmirczak, J.M., T.A., C.M.M., R.C., F. Kamdar), University of Minnesota, Minneapolis. Search for more papers by this author , Marie SteinerMarie Steiner Divisions of Hematology and Oncology and Critical Care (M.S.), University of Minnesota, Minneapolis. Search for more papers by this author , Brenden BoyleBrenden Boyle https://orcid.org/0000-0002-4403-2691 Division of Cardiology, Department of Medicine (V.M., B.B., F. Kazmirczak, J.M., T.A., C.M.M., R.C., F. Kamdar), University of Minnesota, Minneapolis. Search for more papers by this author , Felipe KazmirczakFelipe Kazmirczak https://orcid.org/0000-0001-8998-7259 Division of Cardiology, Department of Medicine (V.M., B.B., F. Kazmirczak, J.M., T.A., C.M.M., R.C., F. Kamdar), University of Minnesota, Minneapolis. Search for more papers by this author , Jeremy MarkowitzJeremy Markowitz https://orcid.org/0000-0001-9389-432X Division of Cardiology, Department of Medicine (V.M., B.B., F. Kazmirczak, J.M., T.A., C.M.M., R.C., F. Kamdar), University of Minnesota, Minneapolis. Search for more papers by this author , Tamas AlexyTamas Alexy Division of Cardiology, Department of Medicine (V.M., B.B., F. Kazmirczak, J.M., T.A., C.M.M., R.C., F. Kamdar), University of Minnesota, Minneapolis. Search for more papers by this author , Andrew ShafferAndrew Shaffer https://orcid.org/0000-0002-7089-3241 Division of Cardiothoracic Surgery, Department of Surgery (A.S., R.J.), University of Minnesota, Minneapolis. Search for more papers by this author , Ranjit JohnRanjit John Division of Cardiothoracic Surgery, Department of Surgery (A.S., R.J.), University of Minnesota, Minneapolis. Search for more papers by this author , Cindy M. MartinCindy M. Martin Division of Cardiology, Department of Medicine (V.M., B.B., F. Kazmirczak, J.M., T.A., C.M.M., R.C., F. Kamdar), University of Minnesota, Minneapolis. Search for more papers by this author , Rebecca CogswellRebecca Cogswell Division of Cardiology, Department of Medicine (V.M., B.B., F. Kazmirczak, J.M., T.A., C.M.M., R.C., F. Kamdar), University of Minnesota, Minneapolis. Search for more papers by this author and Forum KamdarForum Kamdar Correspondence to: Forum Kamdar, MD, PhD, University of Minnesota Mayo Clinic 508, 420 Delaware St SE, Minneapolis, MN 55455. Email E-mail Address: [email protected] https://orcid.org/0000-0003-3218-0467 Division of Cardiology, Department of Medicine (V.M., B.B., F. Kazmirczak, J.M., T.A., C.M.M., R.C., F. Kamdar), University of Minnesota, Minneapolis. Search for more papers by this author Originally published15 Nov 2021https://doi.org/10.1161/CIRCHEARTFAILURE.121.008334Circulation: Heart Failure. 2021;14:e008334Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: November 15, 2021: Ahead of Print A 64-year-old man with a HeartMate 3 left ventricular assist device (LVAD) implanted as a bridge to transplant 2 years ago for nonischemic cardiomyopathy was admitted with pneumonia in the setting of coronavirus disease-2019 (COVID-19).Dexamethasone and remdesivir were initiated for COVID-19 treatment. LVAD parameters on admission were stable (speed 5500 rpm; flow 5.1 L/min; power 4.4 W; pulsatility index 3.2). Basic metabolic panel was normal, International Normalized Ratio (INR) was 4.2 in the setting of warfarin therapy, and CRP (C-reactive protein) was 130 mg/L. LDH (lactate dehydrogenase) was mildly elevated at 375 U/L, from his baseline of 200 U/L. ECG showed no evidence of myocardial ischemia, but troponin-I was elevated at 0.475 ng/mL (normal <0.015 ng/mL; Figure).Download figureDownload PowerPointFigure. Patient timeline and thrombus images.Top, A, Clinical timeline of outpatient events and inpatient hospitalization, noting progression of clot burden in relation to left ventricular assist device (LVAD) parameters and coronavirus disease-2019 (COVID-19)–specific treatment. Bottom, Contrast-enhanced cardiac computed tomography demonstrating a large thrombus (*) in the outflow graft of a HeartMate 3 LVAD. Axial (B), coronal (D), and sagittal (C and E) planes are shown. LDH indicates lactate dehydrogenase; and PCR, polymerase chain reaction.Initial computed tomography (CT) chest incidentally identified a filling defect within the outflow graft. Cardiac CT angiogram confirmed a nonocclusive thrombus extending throughout the entire outflow cannula reaching 50% stenosis at 2.6 cm from the aortic anastomosis site with a free luminal area of 1.53 cm2. No anatomic complications including bending or twisting of the outflow graft was present. A small nonocclusive thrombus was also noted in the celiac artery. Left ventricular internal diameter at end diastole was 5.1 cm by echocardiography (baseline for patient) with an ejection fraction <20%. Septum was midline and aortic valve remained closed during the cardiac cycle. Limited transthoracic imaging windows prevented assessment of inflow and outflow velocities.Patient’s respiratory status worsened over the next day necessitating endotracheal intubation. LVAD flows declined to 2.0 to 2.5 L/min without changes in pulsatility index or power. Low dose vitamin K was administered due to rising INR and a high-intensity unfractionated heparin drip was initiated. A repeat chest CT angiogram showed interval increase of the thrombus burden within the outflow cannula with the free luminal area declining to 0.8 cm2 near the aortic anastomosis. Repeat echocardiogram showed an left ventricular internal diameter at end diastole of 6.3 cm and the aortic valve was opening with each beat. Dobutamine was initiated for hemodynamic support. A bivalirudin infusion and dipyridamole 25 mg 3× a day were started, and aspirin was escalated to 325 mg. Serial thrombelastography was performed to ensure adequate platelet inhibition. LDH decreased from a peak of 995 U/L on hospital day 3; however, IL (interleukin)-6 levels were still rising, peaking at 48 pg/ml (normal <3.0 pg/mL). Given ongoing COVID-19 acute respiratory distress syndrome, LVAD exchange was not pursued due to concerns about hypercoagulability and risk of thrombosing a new device. In the next 2 days, the patient had increasing supraventricular and ventricular arrhythmias and ultimately developed cardiogenic shock. Final CT angiogram showed further progression of the thrombus burden along the entire outflow graft with subtotal occlusion at the aortic anastomosis site and a measured luminal area of 0.47 cm2.Given the patient’s worsening hemodynamics and COVID-19–related acute respiratory distress syndrome, his family elected to pursue comfort measures.DiscussionTo our knowledge, this is the first report of a patient with a Heartmate 3 LVAD developing rapidly progressive outflow graft thrombus in the setting of COVID-19. One other case is published of a woman with a Heartmate 2 device who developed pump thrombosis in the setting of COVID-19 infection; however, she had 2 similar episodes in the past necessitating LVAD exchanges.1 Our patient had no prior history of thrombosis, hypercoagulability disorder, had been therapeutically anticoagulated, and there were no clinical concerns for outflow graft thrombosis on presentation. The outflow graft and celiac artery thrombi were an incidental finding on his initial CT scan. The admission LDH was mildly elevated; however, it was thought to be related to the underlying COVID-19 infection. Prior studies have described elevated serum LDH in patients with COVID-19, and its level correlated with disease severity as well as mortality.2 This observation may hinder the value of LDH predicting thrombosis in the LVAD population.Other authors have described their experience treating patients with a durable mechanical support device during COVID-19 infection. Inflammatory markers are frequently elevated. Patients may require vitamin K administration followed by heparin infusion to allow more frequent anticoagulation adjustment and tighter monitoring.3–5 D-dimer, prothrombin time, platelet count, and fibrinogen level should be monitored routinely in all patients with COVID-19 infection to risk stratify individual bleeding and clotting potential.6 It has been theorized that the compulsory anticoagulation required in patients with LVAD may reduce the risk of thromboembolic complications7; however, our case argues that LVAD patients with COVID may not be adequately protected. Reports have noted higher rates of clotting of extracorporeal membrane oxygenation circuits and intravascular access devices, due to endothelial trauma, inflammation and hypercoagulability caused by COVID-19.8,9 Guidance has been released pertinent to the management of patients with LVAD and COVID-19 infection.10 At the time of this report, there is not enough data to guide antithrombotic management decisions, and local expertise should be utilized. Larger data is needed to provide evidence for best practices.Article InformationAcknowledgmentsWe thank Cynthia Faraday for figure assistance.Sources of FundingThis work was supported by a Doris Duke Charitable Foundation Clinical Scientist Development Award and a Women’s Early Career Research Award to F. Kamdar.DisclosuresDr Alexy is a consultant at SqTherapeutics. Dr John is a consultant and receives research grants from Abbott and Medtronic. Dr Cogswell reports receiving fees for consulting and speaker's bureau from Abbott and is a consultant and husband’s employer at Medtronic. The other authors report no conflicts.FootnotesFor Sources of Funding and Disclosures, see page 1359.Correspondence to: Forum Kamdar, MD, PhD, University of Minnesota Mayo Clinic 508, 420 Delaware St SE, Minneapolis, MN 55455. Email [email protected]edu