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upper quadrant and the driveline was bisected and withdrawn from the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.