Introduction
Cardiovascular disease remains the 2rd cause of death in the developed world with CHF being a large component. Orthotropic heart transplantation is still the best therapeutic option for end-stage CHF but the number of transplant has remained relatively stable since the 2000’s.
For carefully selected patients, left ventricular assist devices (LVAD) have become a standard therapy as bridging to therapy, bridging to recovery, or more recently as destination therapy (DT).
Ventricular arrhythmias (VA) are largely a potentially life threatening rhythm if not converted/fixed. LVAD patients have VA at a variable reported prevalence of 18.3% to 59%. VA can have a variable clinical presentation, the most consistent finding in LVAD patients presenting with persistent VA is drop in device pulsatility index and /or flow due to inadequate preload.
We reported a case of a DT LVAD patient that presented to the clinic with a VA.
Case Description
A 44 y/o female with ischemic cardiomyopathy on LVAD support since 2008. Currently with Heart Ware as DT last device exchanged 2012. Presented to the clinic due to “remote monitoring” report of 80% reduction of pulsatility in her LVAD. She denied all symptomatology. Upon presentation she was completely stable, blood pressure 75mmHg by Doppler. Pump flows 4.4 L/min, 2880 rpm, with a power of 4.9. Laboratory values with normal CBC and CMP, therapeutic INR 2.56 and stable NT-proBNP 2341.
She presented with First EKG (Figure A). Amiodarone infusion after bolus was given and she was started on a heparin infusion. Following day she persisted in VF (Figure B), therefore she underwent TEE under sedation, which revealed only a small atrial thrombus (1.8mm). Decision was made to proceed with DC cardioversion. One attempt with 200 J was unsuccessful. Next attempt was made with 560 J with transecting vectors, which was successful in re-establishing atrial fibrillation rhythm. Afterwards she converted to a normal sinus rhythm (Figure C)
Subsequently she was transitioned to oral amiodarone. Additionally she underwent placement of an implantable loop recorder to observe her for further ventricular arrhythmia.
Discussion
The therapeutic approach to VF in patients with LVAD support is often problematic as there is limited experience on the available options. VA associated with LVAD are common and correlate with increased mortality.
Despite most LVAD patients can tolerate VA, the majority of LVAD require adequate LV filling and decent right ventricular function to maintain optimal output. Persistent VA can lead to severe RV dysfunction and subsequently result in poor left ventricular filling and LVAD malfunction.
Previously described there are several cases of asymptomatic VF in LVAD patients; but they have been in older support devices, have AICD shock as presenting sign and presented shortly in the perioperative period. Our patient is unique as she has been on LVAD support for over 9years, presented with VA due to monitor alarm in flows, and doesn’t have an AICD.
Her VA that was successfully cardioverted with 560J after amiodarone loading and documenting no significant thrombotic disease by TEE, which is a treatment pathway previously described.
