Successful management of aortic root thrombosis in a patient with Heartmate 3.

Abstract

A 74-year-old female with ischemic cardiomyopathy underwent Heartmate 3 (HM 3) implantation for advanced heart failure as destination therapy. Anticoagulation with unfractionated heparin was started within 24 h after implantation. Warfarin and aspirin were started on post-operative Day 3. The patient was mostly in the therapeutic range of the international normalized ratio and activated partial thromboplastin time. On a post-operative Day 11, the patient took a chest computed tomography (CT) for the evaluation of new-onset dyspnea. The CT demonstrated a large aortic root thrombosis (ART) measuring 2.9 cm in maximum diameter covering all three cusps of the aortic valve (AV) (Panel A) and showed a close location with the left coronary ostium (Panel B, arrow: left coronary ostium). After a multidisciplinary discussion with heart failure physicians, cardiac surgeons, and cardiac imaging specialists, we decided to intensify anticoagulation and withhold thrombectomy. We also increased the pump speed in an effort to minimize the AV motion for the prevention of systemic embolization or myocardial infarction. After 3 weeks, follow-up CT showed regression of the ART (Panel C). Accordingly, we lowered the left ventricular assist device (LVAD) pump speed for adequate AV opening to prevent recurrent ART. Three-dimensional (3D) CT reconstruction of the LVAD (Panel D) and follow-up chest x-ray (Panel E) showed well positioned LVAD. The patient was discharged and has been doing well for more than a year with a good therapeutic target range of anticoagulation.