Treatment of Left Ventricular Assist Device Thrombosis With Extended Catheter-Directed Intraventricular Thrombolytic Therapy

Abstract

Continuous flow left ventricular assist devices (LVAD) are used in patients with advanced heart failure, either as bridge to transplant or as destination therapy.1 Because current generation continuous flow LVADs activate the coagulation system, anticoagulant therapy with warfarin is recommended to minimize the risk of device thrombosis.2 Occasionally, however, device thrombosis may still occur, which may necessitate surgical LVAD exchange. Because of the relatively high morbidity and mortality associated with a surgical LVAD exchange, alternative methods to abort LVAD thromboses short of surgical intervention would be attractive. Recently, resolution of device thrombosis with catheter-directed intraventricular administration of a single bolus dose of fibrinolytic therapy has been reported.3,4 Here, we report the successful resolution of 2 consecutive cases of LVAD thrombosis using continuous catheter-directed intraventricular administration of fibrinolytics for an extended period in patients who did not respond to the initial bolus dose of fibrinolytics without resorting to surgical LVAD exchange. A 45-year-old man with HeartMate II (Thoratec Corporation, Pleasanton, CA) LVAD as destination therapy for dilated cardiomyopathy presented with dark red urine 11 months after device implantation. Further evaluation revealed a subtherapeutic international normalized ratio (INR) (1.4), markedly elevated serum lactate dehydrogenase (LDH; 4010 U/L), low serum haptoglobin (<20 mg/dL), mild hyperbilirubinemia (1.2 mg/dL), and elevated plasma-free hemoglobin (15.4 mg/dL), consistent with hemolysis. Review of logged waveform files revealed no power …