Onset Of Acute Heart Failure Research Articles

Repair of Ruptured Sinus of Valsalva Aneurysm: Rare Cause of Acute Onset Congestive Heart Failure in Down’s Syndrome

A 20-year-old boy with Down´s syndrome presented to the emergency department with new onset acute heart failure. Right side chest effusion and cardiomegaly was observed on chest x-ray. A mobile aneurysmal sac protruding into the right atrium was detected and a ruptured aneurysm of the right coronary sinus of Valsalva was observed in transthoracic echocardiogram. Cardiac angiography catheterization confirmed the diagnosis. Surgical repair consisting of aneurysm resection and defect closure was performed shortly after with pericardium reinforced suture through the right atrium. The patient was discharged uneventfully.

Differences in clinical characteristics and outcome of de novo heart failure compared to acutely decompensated chronic heart failure – systematic review and meta-analysis

Background Recent evidence showed that the characteristics and outcome of those with de novo heart failure (HF) and acutely decompensated chronic heart failure (ADCHF) were different. We aimed to perform a comprehensive search on the clinical characteristics and outcome of patients with de novo HF and ADCHF. Methods We performed a comprehensive search on de novo/new onset acute HF vs ADCHF from inception up until December 2019. Results There were 38320 patients from 15 studies. De novo HF were younger and, had less prevalent hypertension, diabetes mellitus, ischaemic heart disease, chronic obstructive pulmonary disease, atrial fibrillation, and history of stroke/transient ischaemic attack compared to ADCHF. Five studies showed a lower NT-proBNP in de novo HF patients, while one study showed no difference. Valvular heart disease as aetiology of heart failure was less frequent in de novo HF, and upon sensitivity analysis, hypertensive heart disease was more frequent in de novo HF. As for precipitating factors, ACS (OR 2.42; I2:89%) was more frequently seen in de novo HF, whereas infection was less frequently (OR 0.69; I2:32%) in ADCHF. De novo HF was associated with a significantly lower 3-month mortality (OR 0.63; I2:91%) and 1-year (OR 0.59; I2:59%) mortality. Meta-regression showed that 1-year mortality did not significantly vary with age (p = .106), baseline ejection fraction (p = .703), or HF reduced ejection fraction (p = .262). Conclusion Risk factors, aetiology, and precipitating factors of HF in de novo and ADCHF differ. De novo HF also had lower 1-year mortality and 3-month mortality compared to ADCHF.

Impact of concurrent right ventricular myocardial infarction on outcomes among patients with left ventricular myocardial infarction

To compare in-hospital outcomes between left ventricular myocardial infarction (LVMI) patients with and without right ventricular myocardial infarction (RVMI). Patients with acute ST-segment elevation MI (STEMI) undergoing primary percutaneous coronary intervention (PCI) were enrolled and divided into LVMI with and without RVMI groups. Between-group differences and in-hospital outcomes were compared. Compared to patients without RVMI, patients with RVMI were more likely to be male, have higher body mass index, serum levels of C-reactive protein (8.9 ± 2.4 vs 6.2 ± 2.1 mg/dL), B-type natriuretic peptide (1295 ± 340 vs 872 ± 166 pg/mL) and cardiac troponin-I (8.6 ± 2.9 vs 5.2 ± 2.1 ng/mL), and have diabetes (36.3% vs 3.4%) and dyslipidemia (53.4% vs 48.1%). Patients with RVMI had lower left and right ventricular ejection fraction (50.5 ± 5.6% vs 53.4 ± 3.8% and 33.6 ± 2.9% vs 45.7 ± 2.0%), but had higher mean pulmonary artery pressure (30.6 ± 3.3 vs 23.8 ± 3.1 mm Hg). Compared to patients without RVMI, patients with RVMI had higher odds of in-hospital all-cause mortality (4.1% vs 1.0%) and new onset acute heart failure (3.4% vs 1.0%). After adjusted for confounding factors, LVMI with RVMI remained independently associated with composite outcomes, with odds ratio 1.66 (95% confidence interval 1.39–2.04). Compared to isolated LVMI patients, those with concomitant RVMI have higher odds of in-hospital complications, particularly all-cause mortality and new onset acute heart failure.

A Clinical Review of COVID-19 Associated Myocarditis

The Coronavirus 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2(SARS COV-2) which can cause multi-organ dysfunction with noteworthy ramifications for patients' cardiovascular consideration. Complications like myocarditis, myocardial injury, acute-onset heart failure, acute coronary syndrome, arrhythmia have been reported. However, a limited number of case reports, retrospective studies, and impairing factors, including the lack of proper diagnostic modalities for COVID-19 associated myocarditis, have made the exact incidence of myocarditis from COVID-19 unclear. In this paper, we have analyzed peer-reviewed articles to highlight COVID-19 myocarditis and outline the associated risk factors, pathophysiology, symptoms, diagnosis, and management of such patients. This is to ensure rapid triage, so their treatment is not compromised and thereby averting fatal complications from it.

Mid‐regional pro‐atrial natriuretic peptide for the early detection of non‐acute heart failure

Diagnosing non-acute heart failure (HF) remains challenging, notably in the early stages of the syndrome. The diagnostic value of mid-regional pro-atrial natriuretic peptide (MR-proANP) has been proven in acute onset HF, but its role in early non-acute HF is unknown. We aimed to determine the diagnostic value of MR-proANP in suspected non-acute HF. In total, 721 people suspected of non-acute HF in primary care underwent standardised diagnostic work-up including chest X-ray, electrocardiogram, N-terminal pro-B-type natriuretic peptide (NT-proBNP) measurement and echocardiography. Of these, 245 people underwent additional MR-proANP measurements. The outcome of HF was assessed by an expert panel comprised of two cardiologists and one expert physician, who used all available diagnostic information including echocardiography, but were blinded to biomarker results. Of the 245 people (mean age 71.0years, 62.9% female), 72 (29.4%) were diagnosed with HF. The c-statistics of MR-proANP and NT-proBNP as single diagnostic test were 0.77 [95% confidence interval (CI) 0.70-0.84] and 0.79 (95% CI 0.73-0.86), respectively. The cut-point with the highest accuracy for MR-proANP was 120 pmol/L [sensitivity/specificity/positive predictive value (PPV)/negative predictive value (NPV) 0.72, 0.69, 0.46, and 0.86, respectively], and the best exclusionary cut-point was 40 pmol/L (sensitivity/specificity/PPV/NPV 0.99, 0.06, 0.30, and 0.92, respectively). After addition of MR-proANP on top of a previously validated clinical model, the c-statistic rose from 0.82 (95% CI 0.76-0.88) to 0.86 (95% CI 0.80-0.92), and with the addition of NT-proBNP to 0.87 (95% CI 0.81-0.92). No sex interactions between the biomarkers and HF were found in the multivariable models. MR-proANP provides added diagnostic value in suspected non-acute HF, similar to NT-proBNP.

Serum Concentrations of Citrate, Tyrosine, 2- and 3- Hydroxybutyrate are Associated with Increased 3-Month Mortality in Acute Heart Failure Patients

Considering the already established relationship between the extent of the metabolic dysfunction and the severity of heart failure (HF), it is conceivable that the metabolomic profile of the serum may have a prognostic capacity for 3-month mortality in acute heart failure (AHF). Out of 152 recruited patients, 130 serum samples were subjected to the metabolomic analyses. The 3-month mortality rate was 24.6% (32 patients). Metabolomic profiling by nuclear magnetic resonance spectroscopy found that the serum levels of 2-hydroxybutyrate (2-HB), 3-hydoxybutyrate (3-HB), lactate, citrate, and tyrosine, were higher in patients who died within 3 months compared to those who were alive 3 months after onset of AHF, which was confirmed by univariable logistic regression analyses (p = 0.009, p = 0.005, p = 0.008, p<0.001, and p<0.001, respectively). These associations still remained significant for all tested metabolites except for lactate after adjusting for established prognostic parameters in HF. In conclusion, serum levels of 2-HB, 3-HB, tyrosine, and citrate measured at admission are associated with an increased 3-month mortality rate in AHF patients and might thus be of prognostic value in AHF.

HDL subclasses and mortality in acute heart failure patients

The link between HDL subclasses and the prognosis of cardiovascular diseases remains controversial. We thus evaluated the prognostic value of the HDL subclasses 3 and 2 cholesterol (HDL3-C, HDL2-C) as well as of total HDL-C for 3-month mortality in acute heart failure (AHF) patients. The serum levels of HDL3-C and total HDL-C were determined by detergent-based homogeneous assay. HDL2-C was computed by the difference between total HDL-C and HDL3-C. Out of the 132 analyzed patients, 35 (26.5%) died within three months after onset of AHF. Univariate logistic regression analyses revealed a significant inverse association of HDL3-C (odds ratio (OR) 0.46 per 1-SD increase, 95% confidence interval (CI) 0.27–0.72, p = 0.001) with 3-month mortality, whereas concentrations of total HDL-C and HDL2-C showed no significant association. After adjustment for various laboratory and clinical parameters known to be associated with mortality in heart failure patients, HDL3-C concentrations remained significantly associated with 3-month mortality (OR 0.34 per 1-SD increase, 95% CI 0.15–0.74, p =0.010). We conclude that low admission serum levels of HDL3-C are associated with an increased 3-month mortality in AHF patients, whereas total HDL-C and HDL2-C showed no association. HDL3-C might thus be useful as a prognostic parameter in AHF.

Severe new onset acute heart failure in a 48-year-old male, found to have congenital bicuspid aortic valve with critical aortic stenosis and ascending aortic aneurysm

Case Report: A 48-year-old male who has never seen a doctor as an adult presented to the Emergency Department with worsening shortness of breath over the past two weeks. He had orthopnea and dyspnea on exertion, a mild “frothy” cough without wheezing, abdominal distension, bilateral leg swelling, and no chest pain. He recalls that at age 10 he was evaluated for a murmur and had a cardiac catheterization without any interventions. No family history of cardiac disease. Vital signs were normal on room air. Exam was notable for lungs with bibasilar crackles, jugular venous distension, +4/6 systolic murmur loudest at the …

Severe new onset acute heart failure in a 48-year-old male, found to have congenital bicuspid aortic valve with critical aortic stenosis and ascending aortic aneurysm

Severe new onset acute heart failure in a 48-year-old male, found to have congenital bicuspid aortic valve with critical aortic stenosis and ascending aortic aneurysm

Survival in Intermacs 1 &amp; 2 Patients After LVAD Therapy: Does Chronicity of Heart Failure Matter?

Few studies have addressed the difference in survival after LVAD that may exist in patients without longstanding cardiomyopathy who are in cardiogenic shock within Intermacs Category 1 & 2. We hypothesized that within this group with the most critical illness immediately preceding VAD, those with acute onset of heart failure (HF) have improved outcomes as compared to those with chronic disease, who may suffer from longstanding end-organ dysfunction.

Fulminant Myocarditis: A Review of the Current Literature

Myocarditis is an inflammatory disease of the myocardium with a wide spectrum of symptoms and severity. Fulminant myocarditis is a small cohort of this disease that tends to present with sudden onset acute heart failure, cardiogenic shock, or life-threatening arrhythmias. The most common type, and the one with the best likelihood for recovery, is lymphocytic myocarditis. More rare, and often more fatal, forms are eosinophilic myocarditis and giant cell myocarditis. Delayed recognition and lack of standardized therapy guidelines continue to challenge clinicians treating these critically ill patients. This article will review the most up-to-date literature regarding recognition and recommended treatment for fulminant myocarditis as it pertains to clinical practice.

Comparision of the treatment and short-term and one-year prognosis from acute heart failure in tertiary hospitals versus secondary hospitals--findings from Beijing Acute Heart Failure Registry (Beijing AHF Registry)

Objective To assess and compare the incidence, clinical characteristics, treatment, and prognosis of acute heart failure patients from different grades hospitals in Beijing. Methods In this prospective internet prognosis registered study (Beijing AHF Registry), a total of 3 335 consecutive patients admitted to 14 emergency departments in Beijing from January 1st 2011 to September 23rd 2012 were enrolled. According to hospital grade, these patients were divided into two groups, 349 patients were from secondary hospitals, and 2 956 patients were from tertiary hospitals. Results Among the 3 335 patients, the medium age was 71 (58, 79) years, and male accounted for 53.16%. The most common underlying disease were coronary disease (43.27%), hypertension (17.73%), cardiomyopathy (16.07%) etc. The average treatment time in Emergency Department was 66.82 h. The emergency department mortality rate was 3.81% (127 cases). The 30-day and 1-year cumulative all-cause mortality were 15.3% and 32.27%, respectively. The 30-day and 1-year cumulative all-cause readmission were 15.64% and 46.89%, respectively. Compared with patients in tertiary hospitals, patients in secondary hospitals had more onset acute heart failure patients (63.64% vs. 49.93%), shorter emergency department treatment time (12 h vs. 41 h) , lower discharge rate (3.43% vs.37.45%) and emergency department mortality(1.58% vs. 4.09%). Compared with those in tertiary hospitals, 1-year cumulative all-cause mortality (25.6% vs.33.2%), cardiovascular disease mortality (20.2% vs.26.0%),aggravated heart failure mortality (22.4% vs.28.8%)were lower in secondary hospitals. Following propensity score matching, compared to tertiary hospitals, patients in secondary hospitals showed lower utilization rate of beta-blockers and ACEI/ARB (4.51% vs. 28.17%, 1.41% vs. 9.58%), except the pironolactone. Conclusion Acute heart failure in emergency department is associated with a high mortality rate and readmission rate. There is still a big gap between guidelines recommend medication current treatments for acute heart failure. Key words: Acute heart failure; Prognosis; Treatment; Mortality; Emergency department

The Real Life Data of Hospitalized Patients with Heart Failure: on behalf of Journey HF-TR study investigators

Objective:Acute heart failure (AHF) is a life-threatening clinical syndrome characterized by rapid onset of heart failure (HF) symptoms and signs and requires urgent therapy. The aim of the present study was to evaluate the overall clinical characteristics, management, and in-hospital outcomes of hospitalized patients with AHF in a large sample of Turkish population.Methods:The Journey HF-TR study is a cross-sectional, multicenter, non-invasive and observational trial. Patients who were hospitalized with a diagnosis of AHF in the intensive care unit (ICU)/coronary care unit and cardiology wards between September 2015 and September 2016 were included in our study.Results:A total of 1606 (male: 57.2%, mean age: 67.8±13 years) patients who were diagnosed with AHF were enrolled in the study. Seventeen percent of the patients were admitted to the hospital with a diagnosis of new onset AHF. Hypertension (67%) and coronary artery disease (CAD) (59.6%) were the most frequent underlying diseases. Acute coronary syndrome accompanying HF (14.7%), infection (29.3%), arrhythmia (25.1%), renal dysfunction (23%), and non-compliance with medication (23.8%) were the precipitating factors. The median length of stay in the ICU was 3 days (interquartile range, IQR 1–72) and 7 days (IQR 1–72) for in-hospital journey. The guideline recommended medications were less likely used in our patient population (<73%) before admission and were similar to European and US registers at discharge. The in-hospital mortality rate was 7.6%. Hypertension and CAD were the most frequent underlying diseases in our population similar to other European surveys. Although our study population was younger than other registers, in-hospital mortality was high.Conclusion:Analyses of such real-world data will help to prepare a national database and distinctive diagnosis and treatment algorithms and to provide observing compliance with the current European Society of Cardiology guidelines for more effective management of HF.

Acute-onset heart failure secondary to long-standing abuse of alcohol, cocaine, and marijuana

Acute-onset heart failure in a young, otherwise healthy patient can be due to either acquired or congenital etiologies. While some diagnoses carry specific histologic hallmarks, many causes of myocardial injury culminate in the relatively nonspecific morphologic pattern of dilated cardiomyopathy. In such cases, a broad differential diagnosis and close clinicopathologic correlation are essential. Here we describe the acute and chronic histologic features of heart failure arising in the context of long-standing abuse of cocaine, alcohol, and marijuana. The mechanisms of cardiotoxicity are discussed for each drug, with particular emphasis on the amplified cardiac injury caused by concomitant cocaine and alcohol use. Although its histologic features are themselves nonspecific, correlation with clinical history, targeted studies to exclude alternative diagnoses, and careful morphologic examination permit confident diagnosis of cardiomyopathy secondary to polysubstance abuse.

Impact of Triggering Events on Outcomes of Acute Heart Failure

BackgroundThe onset of acute heart failure is known to be associated with increased physical activity and other specific behaviors that can trigger hemodynamic deterioration. This analysis aimed to describe the distribution of triggers in patients hospitalized for acute heart failure, and investigate their effects on in-hospital outcomes. MethodsConsecutive patients hospitalized for acute heart failure between 2010 and 2014 were registered in a multicenter data registration system (72 institutions within Tokyo, Japan). Baseline demographics and in-hospital mortality were extracted from 17,473 patients. Patients with a trigger were grouped based on their triggering event: those with onset during (a) physical activity; (b) sleeping; (c) eating or watching television; (d) bathing or excretion (use of restrooms); and (e) engaging in other activities. These patients were compared with patients without identifiable triggers. Multiple imputation was used for missing data. ResultsPatients were predominantly men (57.1%), with a mean age of 76.0 ± 13.0 years; a triggering event was present in 49.1%. No significant difference in baseline characteristics was noted between groups except for younger age, higher blood pressure, and prevalence of signs of congestion in the trigger-positive group. In-hospital mortality rate was 7.9%. Presence of triggers was positively associated with a reduced risk of in-hospital mortality (adjusted odds ratio 0.79; 95% confidence interval, 0.70-0.90; P = .0003). In a delta-adjusted pattern mixture model, the effect of a triggering event on in-hospital mortality remained consistently significant. ConclusionTriggering events for acute heart failure can provide additional information for risk prediction. Efforts to identify the triggers should be made to classify patients according to risk group.

The Effect of Alcohol Abuse and Tobacco Use in the Development of Early Onset Acute Heart Failure Syndrome

Introduction. Alcohol abuse is a major cause of cardiomyopathy, subsequently leading to heart failure. Aim. To evaluate the incidence of acute heart failure syndrome (AHFS) among patients with alcohol abuse/dependence, and to evaluate the synergistic effect of tobacco use among the same group of patients. Methods: A retrospective analysis was performed on 2,005 patients admitted to our hospital for an acute heart failure syndrome (AHFS) from January 1, 2005 to December 31, 2015. A history of alcohol abuse/dependence was defined as a documentation of alcohol abuse for more than 2 years, or if patients were evaluated at chemical dependency clinic for alcohol abuse. Tobacco use was defined as a documented history of at least 2 years of smoking regardless of the amount of cigarettes consumed. Heart failure with reduced ejection fraction (HFrEF) was defined as having LVEF ≤40%, while heart failure with preserved ejection fraction (HFpEF) was defined as having LVEF >40%. The average age when the first episode of AHFS occurred was calculated. Results: The mean age of our 2,005 AHFS patient population was 69 (Standard deviation 68.2–69.8). Of 2,005 patients admitted for AHFS, 94 patients (4.7%) were found to have a history of alcohol abuse/dependence. Patients with a history of alcohol abuse/dependence appear to develop AHFS about 12 years earlier than non-alcohol abuse patients (P < .001). When tobacco use was incorporated as a risk factor, those with both alcohol abuse and tobacco use seemed to develop AHFS about 10 years earlier than those with a history of either alone (P < .001), and about 16 years earlier when compared to those with neither alcohol abuse nor tobacco use (P < .001). Patients with a history of alcohol abuse were likely to have HFrEF (68.1%) compared to 51.7% in non-alcohol abuse patients (OR: 2, 95% CI: 1.3–3, P < .001). During subgroup analysis, the average age of AHFS in the HFrEF-alcohol abuse group was 56.4 years versus 66.5 years in the HFrEF-non-alcoholic group (P < .001) while the average age in HFpEF-alcoholic group was 61.5 years versus 73 years in HFpEF-non-alcoholic group (P < .0001). Conclusions: The average age of onset of AHFS in patients with alcohol abuse/dependence was significantly lower than in those without alcohol abuse/dependence. Furthermore, patients with alcohol abuse who consumed tobacco developed AHFS at an even earlier age when compared to those with either alcohol abuse/dependence or tobacco use alone, suggesting a possible synergistic effect between these two risk factors in developing early-onset AHFS.

A retrospective study: cardiac MRI of fulminant myocarditis in children—can we evaluate the short-term outcomes?

BackgroundFulminant myocarditis (FM) is an inflammatory disease of the myocardium that results in ventricular systolic dysfunction and causes acute-onset heart failure. Cardiac magnetic resonance (CMR) has become the primary noninvasive tool for the diagnosis and evaluation of myocarditis. The aim of our study was to assess the CMR findings at different course of FM and the short-term outcomes of fulminant myocarditis (FM) in children.MethodsEight FM children with CMR examinations were included in our study. Initial baseline CMR was performed 10 days (range, 7–20 days) after onset of FM and follow-up CMR after 55 days (range, 33–75 days). Cardiac morphology and function and myocardial tissue characterization at baseline and follow-up CMR were compared using paired T-test and Mann–Whitney U test. The clinical data and initial CMR findings were also compared to predict short-term outcomes.ResultsThe median age of eight FM children was 8.5 years old (range, 3–14). The initial CMR findings were most common with early gadolinium enhancement (EGE, 100%), followed by signal increasing on T2WI and late gadolinium enhancement (LGE, 87.5%), increased septal thickness (75.0%) and increased left ventricle ejection fraction (LVEF, 50.0%). Only three LGE (37.5%), one signal increasing on T2WI (12.5%) and one increased LVEF (12.5%) were found at follow-up. Statistically significant differences were found between initial and follow-up CMR abnormalities in the septal thickness, left ventricular end-diastolic diameter (LVEDD), end-systolic volume (ESV), LVEF, left ventricular mass, T2 ratio and LGE area (P = 0.011, P = 0.042, P = 0.016, P = 0.001, P = 0.003, P = 0.011, P = 0.020). The children with full recovery performed higher incidence of III° atrioventricular block (AVB, five cases VS 0 case) and smaller LGE area (104.0 ± 14.5 mm2 VS 138.0 ± 25.2 mm2) at baseline CMR.DiscussionThe CMR findings of FM in children were characteristic and useful for early diagnosis. Full recovery of clinical manifestations, immunological features and CMR findings could be found in most FM children. The presence of III° AVB and smaller LGE area at baseline CMR might indicate better short-term outcomes.

Acute onset heart failure due to Marfan syndrome

A 28-year-old visiting from Central America presented with twenty-four hours of lower extremity swelling, dyspnea and orthopnea. Clinically, she was diagnosed with acute heart failure requiring inotropes with a transthoracic echocardiogram revealing severe mitral regurgitation with a normal ejection fraction. Subsequent transesophageal echocardiogram confirmed severe mitral regurgitation with aortic root dilatation (Z-score: 3.9). She was also found to have arachnodactyly, scoliosis on X-ray and severe mitral valve prolapse. Given her clinical features she was assessed for Marfan syndrome with the modified Ghent nosology systemic score and met diagnostic criteria. A FBN1 genetic test confirmed the diagnosis of Marfan syndrome discovering a frameshift mutation resulting in an inappropriate stop codon and peptide truncation. For patients presenting with heart failure at an atypical age without typical risk factors, rare conditions such as Marfan syndrome should be considered. Marfan syndrome can accurately and quickly be screened for and diagnosed using the systemic score from the modified Ghent nosology.

Outcomes and predictors of recovery in acute-onset cardiomyopathy: A single-center experience of patients undergoing endomyocardial biopsy for new heart failure

About one-third of patients with unexplained acute-onset heart failure (HF) recover left ventricular (LV) function; however, characterization of these patients in the setting of contemporary HF therapies is limited. We aim to describe baseline characteristics and predictors of recovery in patients with acute-onset cardiomyopathy. We previously described 851 patients with unexplained HF undergoing endomyocardial biopsy. In this study, 235 patients with acute-onset HF were further retrospectively examined. Follow-up LV ejection fraction (LVEF) was available for 138 patients. At 1 year, 48 of 138 (33%) had LVEF recovery (follow-up LVEF ≥50%), and 90 of 138 (65%) had incomplete or lack of recovery. Higher cardiac index (P=.019), smaller LV diastolic diameter (P=.002), and lack of an intraventricular conduction delay (IVCD) (P=.002) were associated with LVEF recovery. IVCD (P=.001) and myocarditis (P=.016) were independent predictors of the composite end point of death, LV assist device placement, and/or transplant at 1 year. Those with an IVCD had a significantly lower 1-year survival than those without (P=.007). Patients with a smaller LV end-diastolic diameter, higher cardiac index, and lack of IVCD at presentation for acute-onset HF were more likely to have LVEF recovery. IVCD was a poor prognostic marker in all patients presenting with acute cardiomyopathy.

Bivalirudin Anticoagulation for a Pediatric Patient with Heparin-Induced Thrombocytopenia and Thrombosis Requiring Cardiopulmonary Bypass for Ventricular Assist Device Placement

The direct thrombin inhibitor bivalirudin is an option for anticoagulation in patients with heparin induced thrombocytopenia (HIT) requiring cardiopulmonary bypass (CPB). There are a limited number of reports of pediatric patients in which bivalirudin has been used for anticoagulation for CPB. We present the case of an 11 year old male with acute onset heart failure secondary to idiopathic dilated cardiomyopathy that developed heparin induced thrombocytopenia with thrombosis (HITT). The patient was anticoagulated in the operating room with bivalirudin and placed on CPB for insertion of a HeartWare® Ventricular Assist Device (Heartware®). Modified techniques were utilized. This included use of the Terumo CDI 500 (Terumo Cardiovascular Systems, Inc.) in-line blood gas monitor which contains a heparin coated arterial shunt sensor. We flushed this sensor with buffered saline preoperatively and noted no significant decrease in platelet count postoperatively. The patient was successfully placed on the ventricular assist device and was subsequently listed for heart transplantation.