Ruptured Bullae: A Rare Cause of No-flow Alarms In Ventricular Assist Devices

Abstract

Introduction Bleeding is a potentially deadly complication of anticoagulation in patients with ventricular assist devices. Management of anticoagulation in this population requires a multidisciplinary approach, especially in the setting of life-threatening bleeding. Case Report A 60-year-old female with emphysema and a HeartMate 3 presented with progressive hemoptysis, dyspnea, and right chest pain. Her hemoglobin was 11.1 g/dL (baseline) and her INR was 2.9. Chest CT showed enlargement of a right lung bullae with intra-bullae hemorrhage (Figure 1). Anticoagulation was held. She had symptomatic hypotension that the thoracic surgeons attributed to recent diuretics. On hospital day two, her hemoglobin decreased to 6.1 g/dL, she had low-flow and no-flow alarms, and hypoxic respiratory failure. She required intubation, blood transfusion, and four inotropes/vasopressors. A chest tube drained 2.7 L of blood with hemodynamic improvement. Angiography showed no active contrast extravasation. Her hemothorax persisted and angiography was repeated the third day; failing again to yield a culprit. However, the interventional radiologists empirically plugged the right inferior pulmonary artery and the bloody chest tube output decreased to 200 mL the following day. She underwent surgical washout with removal of 1 L of clot. Anticoagulation was restarted. She had an ischemic stroke without residual neurologic deficit and a ventilator-associated pneumonia and was discharged on the 32nd day. Discussion This patient had a strong indication for anticoagulation but developed a life-threatening bleed. Her initial hemoglobin was at baseline and she had received diuretics prior to arrival which confounded the severity of her condition. Although angiography was nondiagnostic, holding anticoagulation and empiric plugging of the suspected vessel were lifesaving, at the expense of developing a stroke; fortunately, without permanent neurologic deficit. Conclusion/Teaching point This case highlights the importance of coordinated and intensive multidisciplinary management to achieve early bleeding-source control in patients with mechanical circulatory support; especially when that entails challenging hemorrhagic and thromboembolic complications.