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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 3  |  Issue : 2  |  Page : 122-124

Eight months of HeartMate II device support without drug therapy


1 Department of Cardiothoracic Surgery, Mount Sinai Medical Center, New York, NY 10029, USA
2 Mount Sinai Heart, Mount Sinai Medical Center, New York, NY 10029, USA

Date of Web Publication20-Nov-2017

Correspondence Address:
Anelechi C Anyanwu
Department of Cardiothoracic Surgery, Mount Sinai Medical Center, 1190 Fifth Avenue, New York, NY 10029
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpcs.jpcs_30_17

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  Abstract 


Thromboembolic complication rates of 20%–30% were initially a major limitation to the widespread use of left ventricular assist devices. The success of the HeartMate (Thoratec, Corp., Pleasanton, CA, USA) device has been partly due to the reduced incidence of thromboembolic events, although anticoagulation regime has been recommended for this mechanical circulatory support. We here present a case with the placement of HeartMate II in a patient, noncompliant to medical therapy where device worked for 8 months without any anticoagulant or antiplatelet therapy.

Keywords: Anticoagulation, device thrombosis, HeartMate II, no drug therapy, noncompliance


How to cite this article:
Krishan K, Pinney S, Anyanwu AC. Eight months of HeartMate II device support without drug therapy. J Pract Cardiovasc Sci 2017;3:122-4

How to cite this URL:
Krishan K, Pinney S, Anyanwu AC. Eight months of HeartMate II device support without drug therapy. J Pract Cardiovasc Sci [serial online] 2017 [cited 2019 May 20];3:122-4. Available from: http://www.j-pcs.org/text.asp?2017/3/2/122/218805




  Introduction Top


Thromboembolism is a feared complication during use of ventricular assist devices. The success of the HeartMate (Thoratec, Corp., Pleasanton, CA, USA) device has been partly due to the reduced incidence of thromboembolic events. We present a case with the placement of HeartMate II in a patient, where device worked for 8 months without any anticoagulant or antiplatelet therapy.


  Case Report Top


A 53-year-old male with no prior medical history, presented to an outside hospital with fatigue, new onset right bundle branch block, and ST-elevation myocardial infarction. He underwent cardiac catheterization, which showed complete proximal left anterior descending occlusion, a 99% distal left circumflex occlusion, and a complete proximal right coronary artery occlusion. His left ventricular ejection fraction was about 10%, and mixed venous saturation was 19%. He was placed on mechanical ventilation, and an intra-aortic balloon pump was inserted in an outside hospital. He was transferred to our hospital in cardiogenic shock with evidence of shock liver (Aspartate aminotransaminase 3000 u/L, International Normalized Ratio 2.1), acute renal failure (oliguric, creatinine 2.1 mg/dl), acidosis, and pulmonary edema. His echocardiography confirmed the presence of severe right and left ventricular dysfunction, moderate-to-severe mitral regurgitation, moderate tricuspid regurgitation, and ejection fraction of 10%. In addition, along with biventricular dysfunction, his echocardiogram showed dilatation of the left ventricle and thinning out of the septum suggesting long-standing cardiomyopathy. He underwent emergent placement of biventricular assist device (CentriMag, [Thoratec Copr., Pleasanton, CA, USA] on the right and HeartMate II [Thoratec Corp., Pleasanton, CA, USA] on the left side) and tricuspid valve repair with Edwards MC3 annuloplasty ring (Edwards Lifesciences LLC, Irvine, CA, USA). His right ventricular device was explanted on postoperative day 3. On postoperative day 6, he developed bleeding per rectum. Sigmoidoscopy revealed a rectal mass. Histopathology of this mass revealed invasive moderately differentiated adenocarcinoma. On further workup, computerized tomogram (CT) showed metastasis to liver and lungs. His head scan was negative for any secondaries. Aspirin and coumadin were held for a few days due to rectal bleeding but had been recommended to start once bleeding stopped. Palliative chemotherapy and radiation were started while he was in the hospital. He was discharged home 1 month after the surgery. He thereafter refused to take all medications and was repeatedly noncompliant with therapy and did not keep his appointments, neither in heart failure nor in oncology clinics. He did occasionally attend the left ventricular assist devices (LVAD) clinic if he had issues with his peripherals but otherwise remained well in the New York Heart Association I and with only occasional rectal bleeding. Eight months after the procedure, he presented to the emergency room with shortness of breath and slurred speech. The patient said that he had not taken any medication whatsoever since he left the hospital. On assessment, it was found that pump power was high; but otherwise, the device interrogation was unremarkable. All peripheral pulses were palpable. Echocardiogram did not demonstrate flow through the device [Figure 1]b, aortic valve was opening with each beat, there was severe mitral regurgitation, severe left ventricular dysfunction and moderate right ventricular dysfunction. CT scan demonstrated that the outflow graft of the device did not opacify with contrast [Figure 1]a and multiple subacute infarcts in the brain. As he was noncompliant with medical therapy, he was not considered a candidate for pump exchange.
Figure 1: (a) No flow through the outflow graft on contrast computerized tomogram, (b) echocardiogram showing no color flows through the inflow cannula. IFC = Inflow cannula, OFG = Outflow graft, LV = Left ventricle, RV = Right ventricle.

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He was offered to remove the pump to prevent any further thromboembolic event, The presumption being that some flow was still getting through the LVAD resulting in the acute stroke. He underwent removal of the pump with minimally invasive technique described by Yacoub [1] and transventricular, mitral valve repair using the edge-to-edge technique.[2] On examination, his device was found completely thrombosed [Figure 2]. Postprocedural period was uneventful. His echocardiogram at discharge showed ejection fraction of 30% and mild-to-moderate residual mitral regurgitation. He remained noncompliant and never showed up after dismissal from hospital. He refused to take oral antifailure medication. He died at home few weeks later.
Figure 2: Preoperative picture showing thrombus in the device.

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  Discussion Top


Despite considerable improvements in hemodynamic functions, thromboembolism is still a feared complication during use of ventricular assist devices. Due to contact between blood components and the foreign surfaces of the assist device system and altered rheologic conditions, there has always been a risk of thromboembolism and device thrombosis. Therefore, anticoagulation regime and proper follow-up monitoring have been recommended with the use of these devices. Thromboembolic events are less frequent with newer devices compared to older ones due to improvement in design, compatible surface, and more homeostatic environment in these devices. In case of any bleeding event, such as acute gastrointestinal bleeding, withdrawal of anticoagulation is associated with an increased risk for thrombus formation in patients with LVAD.[4] Hence, close follow-up is needed to weigh the risks of thrombosis versus bleeding. Although many patients with bleeding events are maintained without anticoagulation for long periods, usually some antiplatelet inhibition is continued. Our patient took neither warfarin nor antiplatelet agents for 8 months.

As our patient was noncompliant to medical therapy and follow-up, it was difficult to manage the pump thrombosis with any strategy that would include future anticoagulation. This excluded thrombolysis and pump exchange as practical options. Single-center analysis from the United States suggests that the HeartMate II is associated with an extremely low thromboembolic risk and with less stringent requirements for anticoagulation.[3],[4],[5],[6] In one series of 45 patients, 7 patients discontinued warfarin for a total duration of 39.1 patient-months, because of recurrent gastrointestinal bleeding episodes. During the follow-up of 352 patient-months, there was one thromboembolic event and one assist device pump thrombosis treated by intensification of anticoagulation.

Our case validates this increasingly emerging viewpoint. However, paradoxically, our case also reminds us about the critical importance of anticoagulation and antiplatelet therapy in LVAD function as his pump ultimately thrombosed. Long-term management of LVADs without antiplatelet and anticoagulant therapy should therefore not be encouraged.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initial will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Tansley P, Yacoub M. Minimally invasive explantation of implantable left ventricular assist devices. J Thorac Cardiovasc Surg 2002;124:189-91.  Back to cited text no. 1
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2.
Alfieri O, Maisano F, De Bonis M, Stefano PL, Torracca L, Oppizzi M, et al. The double-orifice technique in mitral valve repair: A simple solution for complex problems. J Thorac Cardiovasc Surg 2001;122:674-81.  Back to cited text no. 2
[PUBMED]    
3.
Rothenburger M, Wilhelm MJ, Hammel D, Schmidt C, Tjan TD, Böcker D, et al. Treatment of thrombus formation associated with the MicroMed DeBakey VAD using recombinant tissue plasminogen activator. Circulation 2002;106:I189-92.  Back to cited text no. 3
    
4.
Meyer AL, Kuehn C, Weidemann J, Malehsa D, Bara C, Fischer S, et al. Thrombus formation in a HeartMate II left ventricular assist device. J Thorac Cardiovasc Surg 2008;135:203-4.  Back to cited text no. 4
[PUBMED]    
5.
Tschirkov A, Nikolov D, Tasheva I, Papantchev V. Successful fibrinolysis after acute left ventricular assist device thrombosis. J Heart Lung Transplant 2007;26:553-5.  Back to cited text no. 5
[PUBMED]    
6.
John R, Kamdar F, Liao K, Colvin-Adams M, Miller L, Joyce L, et al. Low thromboembolic risk for patients with the Heartmate II left ventricular assist device. J Thorac Cardiovasc Surg 2008;136:1318-23.  Back to cited text no. 6
[PUBMED]    


    Figures

  [Figure 1], [Figure 2]



 

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