Case Presentation
We present a case of a 35-year-old male with dilated cardiomyopathy and a background of cocaine and anabolic steroids use. A Transthoracic echo in 2018 demonstrated a severely dilated and hypokinetic left ventricle with an ejection fraction of < 20% and an LV end-diastolic dimension of 72mm. Following admission to the cardiac critical care unit, he underwent placement of a Heartmate 3 LVAD on February 14th, 2018 with bridge transplant candidacy INTERMACS profile 3 (inotrope dependant). Subsequent recovery was uncomplicated and he was discharged with follow-up in the community. Nine months post initial implant, he presented with fatigue, dyspnea, and persistent low flow alarms. Subsequent workup demonstrated an outflow graft twist complicated by thrombosis. He underwent a redo sternotomy with pump exchange and bend relief repair. The operative procedure was complicated by extensive adhesions and excess intra-operative bleeding but again an uncomplicated postoperative course and was he discharged home, quickly returning to his usual activities reporting NYHA 1- 2 symptoms and after demonstrating abstinence from substance abuse was listed for cardiac transplant. Unfortunately, he developed a persistent Staphylococcus aureus driveline infection and was managed with chronic suppressive oral antimicrobials with the intermittent need for parenteral therapy during acute flares.
In January 2020, 23 months post initial implant, he was readmitted to the hospital again with persistent low flow alarms, this time entirely asymptomatic. Left ventricle end-diastolic diameter was 59mm on repeat echocardiography with an ejection fraction of 30-35%. Increases in pump speed did not result in any change in LV dimensions, consistent with LVAD obstruction. Six-minute walk demonstrated NYHA class 1 with a total distance of 413 m walked and a perceived exertion score of 2-3/ 10. Outflow graft thrombosis was suspected on CT angiography and was subsequently confirmed on conventional angiogram which showed no flow through the outflow graft on both LV and aortic injections (FIGURE 1a and 1b). Following 2 days of absent flow through LVAD, the device was disconnected from the power supply without any subjective change reported by the patient. Three weeks following, to the reduce risk of progression of driveline infection, an incision was made in the left upper quadrant and the driveline was bisected and withdrawn from the exit site on the right with the remaining HM3 components, including pump and aortic graft left in situ. The patient was continued on his oral anticoagulation to reduce the risk of ventricular thrombus formation with a target INR of 2-3. After the time of this report, he is still thriving, NYHA functional class I with an LV ejection fraction of 40-50% by ECHO and 50% by radionuclide angiography.