Use of biventricular assist devices for acute heart failure after orthotopic liver transplantation: a case report

Abstract

Presenter: Anushi Shah MD | Massachusetts General Hospital Background: Medical co-morbidities in liver transplantation augment surgical risk. We present this case report of a patient with immediate post-operative biventricular failure following liver transplant requiring veno-arterial extracorporeal membrane oxygenation (VA ECMO) and subsequent conversion to minimally invasive biventricular assist devices for cardiac recovery and new graft preservation. Methods: 66-year-old male decompensated alcoholic cirrhotic (MELD-Na 38) on the liver transplant waitlist had a pre-operative ECHO showing no evidence of overt valvular or coronary disease, ejection fraction (EF) 65%. He underwent an liver transplant on veno-venous bypass, our institutional standard procedure. Transesophageal echocardiography (TEE) pre-reperfusion showed normal biventricular function and at the end of the case showed an EF approximately 10-16% with biventricular dysfunction and severe mitral regurgitation requiring epinephrine, norepinephrine, vasopressin and ionotropic support. Due to continued poor perfusion and poor biventricular function in the ICU post-operatively, the patient was placed on VA ECMO for temporary stabilization and subsequent biventricular support using an Impella® 5.5 (Abiomed, Danvers MA) left ventricular assist device (LVAD) via axillary artery graft and a Protek-Duo (CardiacAssist Inc, Pittsburgh PA) percutaneous right ventricular assist device (RVAD) via the right internal jugular vein. Results: Over the course of post-operative days (POD) 3-11, the patient was weaned off pressors, extubated with close monitoring of liver function (Figure 1). Serial transthoracic echocardiography recovery of myocardial function. RVAD and LVAD were removed on POD 8 and POD 13, respectively. The liver graft function was maintained throughout. Serial TTE post mechanical support removal showed his EF had improved to 52%. Conclusion: This is the first report of minimally invasive biventricular support devices used for acute cardiogenic shock status post liver transplantation. We hypothesized that myocardial stress in the setting of the patient’s history of alcohol abuse was the contributing factors of acute global pump failure. A multidisciplinary team approach to prompt mechanical support ensured preservation of liver graft while allowing for cardiac recovery.