Successful Treatment of a Heart mate II Left Ventricular Assist Device Thrombus in the Setting of a Massive Acute Stroke: A Case Report and Review of the Literature

Abstract

A 56-year-old Caucasian male with a cardiac history of severe nonischemic cardiomyopathy, 3 months post Heart Mate II (Thoratec, Pleasanton, CA) Left ventricular Assist Device (LVAD) implantation, presented to the hospital with a history of acute difficulty in breathing, lethargy and decreased mentation per his wife. He was transferred from an outside hospital about 5 hours since presenting there and during which time he was treated for acute heart failure with intra-venous furosemide. On examination, he was found to be in severe respiratory distress and semi-obtunded. On physical exam he had significant right hemiplegia that was not reported from the outside hospital. A "Stroke Code" was called and a stat-non-contrast-enhanced CT brain was ordered. On connecting his LVAD to the base power module, his parameters were: RPM 10,000, Power-12, Pulsatility Index-2.1, and Flow-3-4 L/min, ( Table 1). The higher power and low PI readings in the setting of acute heart failureimmediately raised the suspicion of an acute device thrombus. His wife told us that patient's symptoms of shortness of breath, dizziness and an episode of fall with no loss of consciousness had started about 4 hours prior to presentation at the outside hospital and about 9 hours prior to presentation at our hospital.His past medical history was significant for episodes of gastrointestinal bleeds secondary to small bowel AV fistulas, Vital signs on presentation at the outside hospital were: Temperature 38.1 F, Heart Rate of 90-101 beats/minute, Respiratory Rate 20-40 breaths/ minute, mean arterial pressure of 70 mmHg and oxygen saturation of 94% on VentiMask 40%. On examination at our hospital he was found to be tachypneic at 33 breaths/minute requiring Bi-level positive airway pressure (BiPAP), heart rate-106 beats/minute, mean arterial pressure-64 mmHg and oxygen saturation of 90% on VentiMask 40%. He appeared confused and lethargic. Neck exam was positive for jugular venous distension. He had decreased breath sounds bilaterally and the LVAD hum was heard on cardiac exam. On neurologic exam, he did not follow any commands, was AbstractLeft ventricular assist devices (LVADs) are increasingly used to treat patients with advanced heart failure both as a Bridge-To-Cardiac Transplantation and Destination Therapy. Device thrombosis is a well-known complication of LVADs that can be potentially catastrophic if not diagnosed early and appropriately managed. We present a case of successful treatment of a suspected Heart Mate II thrombus with systemic thrombolysis and Eptifibatide in a patient who presented with signs and symptoms of acute decompensated heart failure and an ischemic stroke. We further compiled published case reports on acute thrombosis management in contemporary continuous flow LVADs, to discern various treatment approaches available for this serious complication. Published research on optimal anti-coagulation management strategy in the setting of acute device thrombosis is limited, primarily due to the size of this cohort but also due to the ...