LVAD (Left Ventricular Assist Device)
Patient Presentation:
N.J. is a 43-year-old right-handed male with a history of non-ischemic cardiomyopathy of unclear etiology, hypertension, and hyperlipidemia who presented to the ER with complaints of 1 month history of progressively worsening SOB, orthopnea, lower extremity swelling, and generalized fatigue. Patient was awake, alert, and oriented and he denied fevers, chills, chest pain, nausea, vomiting, and coughing. He was well-developed, well-nourished, and did not appear to be in acute respiratory distress. Neck was supple, and left jugular vein distension was noted. Bibasilar rales, more left versus the right, and distant heart sounds; normal S1 and S2 with an S3 gallop were heard on auscultation. Lower extremity edema was noted. Vital signs were: BP 101/82, HR 90, RR 20, temperature 35.7°C, O2 Sat 95% on room air.
Differential Diagnoses:
Advanced non-ischemic cardiomyopathy, coronary artery disease, heart failure exacerbation, pneumonia, heart valve disease.
Lab and Diagnostic Studies:
Na+ 141, K+ 4.8, bicarbonate 28, Cl- 101, BUN 13, creatinine 1.3, glucose 67, WBC 5, Hct 41, platelets 162, INR was 5.7, BNP was 2170, Mg++ 1.8, LFTs were normal, LDH 112, HbA1c 5.5, troponin was negative, albumin and protein were normal. Echocardiogram revealed an ejection fraction of 15% to 20% with severely dilated LV and atrium, severely reduced LV systolic function, normal LV wall thickness, moderately dilated right ventricle with moderately reduced systolic function, mild mitral regurgitation, moderate pulmonary hypertension, and mild aortic regurgitation. Cardiac catheterization revealed normal coronary arteries with no obstructive or stenotic disease. Right heart catheterization via right femoral approach revealed normal intracardiac filling pressures and markedly depressed cardiac output. EKG revealed frequent non-sustained ventricular tachycardia (NSVT) and a septal infarct pattern but normal QRS. Chest x-ray revealed mild to moderate congestive changes in the lungs bilaterally.
Treatment:
Patient was diagnosed with advanced cardiomyopathy, stage D left heart failure (HF), moderate right HF, and NSVT. Subsequently he was recommended for a Left Ventricular Assistive Device (LVAD) placement.
An LVAD is a battery-operated mechanical circulatory device that is surgically implanted to help maintain the pumping ability of a failing or weakened LV in illnesses such as end-stage HF, acute or chronic myocarditis, and s/p myocardial infarction. LVADs could be intended for short term use, for example, until a heart gains back its function, or longer term use, typically in HF patients awaiting a donor heart.
Outcome:
While undergoing extensive work-up for LVAD placement to make sure he is medically stable enough for the procedure, the patient was started on IV milrinone to increase the contractility of his failing heart, IV Lasix® for diuresis, and PO amiodarone for his NSVT. Patient responded well with IV milrinone and Lasix®, however, he continued to have non-sustained ventricular tachycardia. Subsequently an implantable cardioverter-defibrillator (ICD) was placed. While awaiting LVAD placement, an intra-aortic balloon pump (IABP) was also placed to reduce the workload of his heart, allowing his heart to pump more blood. Once stable enough for surgery, his IABP was removed and he successfully underwent placement of Heartmate™ II LVAD. S/p surgery, patient had ongoing LVAD teaching and management. Once patient was hemodynamically stable and demonstrated understanding of LVAD management, he was discharged home on PO amiodarone to prevent arrhythmias, lisinopril for BP management, as well as warfarin to reduce his risk of developing blood clots, which is increased with his implanted LVAD and ICD.
Case created by Nafisa Jiddawi, 2012.