Cardiovascular Disease |

Extensive Pulmonary Thromboembolic Disease as a Complication of VAD Therapy FREE TO VIEW

Corinne Sheth, MD; Heather Merry, MD; Lawrence Czer, MD; Ernst Schwarz, MD; Danny Ramzy, MD; Fardad Esmailian, MD; George Chaux, MD
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Cedars Sinai Medical Center, Los Angeles, CA

Chest. 2013;144(4_MeetingAbstracts):120A. doi:10.1378/chest.1702495
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SESSION TITLE: Cardiovascular Case Report Posters I

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Left ventricular assist device (LVAD) therapy as a bridge to transplantation or destination therapy has improved survival and quality of life in end-stage heart failure. Despite these benefits, it has many complications. We describe a patient with extensive pulmonary thromboembolic disease as a complication of VAD therapy.

CASE PRESENTATION: A 47-year-old male with idiopathic dilated cardiomyopathy had a HeartMate II LVAD inserted as bridge to transplantation. He resumed work and exercise. Months later his dyspnea progressed. Chest computed tomography (CT) scan showed multiple pulmonary nodules, diagnosed as atypical pneumonia and treated with moxifloxacin. Transesophageal echocardiogram showed no vegetations. Microbiology was negative. More significantly, he developed right ventricular dysfunction. A TandemHeart RVAD was urgently placed. He improved and was transferred to our institution for a total artificial heart (TAH). On arrival, he was asymptomatic and stable, though bed bound and on full anticoagulation due to the bi-VAD. Repeat chest CT showed progression of numerous irregular pulmonary nodules (Fig 1). Infectious and autoimmune work up was negative. Bronchoscopy with lavage showed diffuse alveolar hemorrhage but negative microbiology and cytology. With still no definitive etiology, anticoagulation was held and video-assisted thoracoscopic biopsy performed. It showed focal organizing thromboembolism in a pulmonary arteriole, consistent with bland emboli from the devices. TAH placement was pursued but was complicated by massive pulmonary hemorrhage likely due to these infarcts. The family withdrew care and the patient expired.

DISCUSSION: Over 6,885 patients have received an FDA-approved durable mechanical circulatory support device. While often used as bridge to transplant, in 2012 more than 40% were destination therapy. Despite significant therapeutic advantages, VAD support has many complications, including bleeding, infection, arrhythmia, respiratory failure, right heart failure, thromboembolism, stroke, and hemolysis. As these devices become more common, the chest physician must become familiar with their mechanism and complications. Our patient had extensive pulmonary thromboembolic disease due to the VAD. Particularly interesting is that the onset occurred when the patient had an LVAD only, though it did progress after RVAD insertion. Thromboembolic complications of LVADs are common, but usually present as stroke or device thrombosis. Pulmonary thromboembolic disease is not commonly reported.

CONCLUSIONS: VAD therapy is widely used to treat advanced heart failure. It is important for the chest physician to be familiar with its complications, particularly potential pulmonary complications of infection, bleeding, and thromboembolic disease.

Reference #1: JK Kirklin, et al. Fifth INTERMACS annual report: Risk factor analysis from more than 6,000 mechanical circulatory support patients. J Heart Lung Transplant. Vol 32, Iss 2, Feb 2013, 141-156

DISCLOSURE: The following authors have nothing to disclose: Corinne Sheth, Heather Merry, Lawrence Czer, Ernst Schwarz, Danny Ramzy, Fardad Esmailian, George Chaux

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