From Recovery to Transplant: One Patient's Journey Tonya Elliott, RN, MSN Assist Device and Thoracic Transplant Coordinator Inova Transplant Center at Inova Fairfax Hospital Falls Church, VA Introduction Heart failure (HF) is estimated to affect 4 to 5 million Americans, with 550,000 new cases reported annually. In the past three decades, both the incidence and prevalence of HF have increased. Advances in the treatment of HF and early intervention to prevent decompensation may delay disease progression and improve survival. Tools in our armamentarium for heart recovery and/or heart replacement, when medical options have been exhausted, may include the surgical implantation of ventricular assist devices (VAD). Indications for VAD implants are bridge to recovery (post-mi, post-cardiotomy syndrome), bridge to transplant, and destination therapy (DT therapy). Currently, eight different VAD devices are FDA approved for heart recovery or replacement. About 140 VAD/transplant centers exist across the United States. These centers implant at least one of these devices and most centers have two or more VAD models with implant selection based on clinical presentation and indication. When patients acutely decompensate during the evolution of an MI or deteriorate in the operating room during open heart surgery, the implantation of a VAD can allow for stabilization and further assessment of myocardial recovery. This case study presents the use of a VAD system that was initially used for post-cardiotomy support but then served as a bridge to transplant. Case Presentation: Background Information: HISTORY OF PRESENT ILLNESS: 50-year-old male with no significant past medical history and no prescribed medications, presented to a local emergency department on September 24, 2006. He had been on a fishing trip with some friends. He complained of nausea, vomiting, and diarrhea starting around 10 p.m. the previous night. The patient dismissed the GI symptoms as benign. Although he also had substernal chest pain, he minimized this symptom to his friends. His pain lasted until 8 a.m. in the morning. He presented more than 10 hours after the pain started. PAST MEDICAL HISTORY: No significant past medical history as per family. ALLERGIES: None.
MEDICATIONS: None. SOCIAL HISTORY: Married with one child, daughter. Owns his own business. 30 pack year history of smoking, social drinker, no current illicit drug use. FAMILY HISTORY: Grandfather had a myocardial infarction at age 55. DIAGNOSTICS: ECG showed ST elevation in leads V3 to V6; given a presumptive diagnosis of an acute anterior wall myocardial infarction. (Sent to Cath Lab.) Cardiac catheterization: 100% occlusion of the LAD. 100% occlusion of the left circumflex. Complex 90% stenosis of the right coronary artery. Left ventriculogram showed an ejection fraction of 15% to 20% with 2 to 3+ mitral regurgitation. PA pressure of 43/36 and a wedge pressure of 30. The interventional cardiologist was unable to cross the LAD lesion, but the left circumflex lesion was able to be ballooned and stented with good angiographic results and a TIMI-3 flow in the obtuse marginal-2 artery. Course of treatment: Sept 24/ Day of Admission: Patient continued to deteriorate and was sent for emergency coronary artery bypass graft (CABG) surgery. The surgeon performed 3-vessel CABG. The patient was unable to separate from bypass and required the implantation of an Abiomed left ventricular assist device (LVAD), the BVS 5000 column (Figure 1). Postoperative bleeding required re-exploration and evacuation of a blood clot within the first 24 hours. The patient s hemoglobin/hematocrit dropped to 7.5/21.3. His chest remained open due to the swelling from the emergent surgery. The LVAD produced 5 Liters of blood flow. He required multiple pressors including milrinone and norepinephrine. Heparin was initiated after the bleeding was controlled because of the risk of clotting in the VAD. The target activated partial prothrombin time (aptt) is 2 to 2.5 times control or 58 82 seconds. His renal function was initially poor with creatinine levels of 3.0 3.5 for several days, but this normalized. The plan was to support the patient with the LVAD with the hope that the myocardium would recover due to the bypass surgery. Sept 28: He returned to the OR for possible explantation of the VAD if his heart function had improved. Clot had been noted in the inflow and outflow chambers, hastening the attempt to remove the VAD due to the fear of embolic stroke. When the patient did not show significant myocardial recovery as the VAD support was decreased, the clotted
VAD was changed to reduce the risk of embolic events. The VAD was switched to a device with an improved longevity, the AB Ventricle (Figure 2). The column Abiomed blood pump has been used for years for short-term recovery after a myocardial infarct or cardiopulmonary bypass for several days. The AB Ventricle, approved by the FDA in 2003, is intended for longer support and can be used for weeks. Figure 1 Figure 2 Oct 1: White clot was noted in the LVAD inflow valve. The next day another clot was noted in the neck of the outflow valve. Oct 3: Progressive thrombocytopenia (platelet count dropped to 100) occurred with an increasing requirement for heparin. HIT antibodies were found in the blood by serotonin release assay. The heparin was changed to argartroban for anticoagulation. CT of head confirmed an embolic CVA. Heart transplantation would not be possible if the CVA was too extensive.
Oct 4: A TEE was performed to assess for myocardial recovery. The EF was estimated to be approximately 40% on a decreased amount of VAD support. Another trial of VAD explantation was planned. Oct 6: The patient returned to the OR again for a weaning attempt. The patient s LV function deteriorated rapidly in the OR when the LVAD settings were weaned. Because he had yet another clot in the LVAD, it was switched out again to another AB Ventricle (Figure 2). The advantage of switching out this device is that it takes about 90 seconds. Due to the inability to wean the VAD off, a full evaluation for cardiac transplant was performed. Oct 17: Extubated. Oct 18: The patient s neurologic state improved slowly. He had residual left-sided weakness. Coumadin was attempted, however, he had another small CVA without residual. He was switched back to argartroban. Oct 27: After a full evaluation he was accepted and listed for transplantation as a status 1A. Oct 30: The patient became the first Abiomed recipient transferred to the step down unit at our institution. The new console allows patients to be more mobile. He remained status 1A during listing as he had thromboembolic complications related to the device. Nov 25: He was successfully transplanted two months after his myocardial infarct. He currently remains at home with his family adjusting to his new medical regimen. Review of Interventions/Treatments: Key VAD concepts Throughout this patient s VAD support, attention was paid to details that preserve the patient s possible transplant status: 1. The surgeons who performed the CABG quickly determined intraoperatively that weaning from bypass would not be possible and implanted the LVAD. Reducing bypass time results in better outcomes. Centers with heart recovery and replacement systems available are able to rapidly evaluate acutely decompensating HF and implant VADs, salvaging patients from poor outcomes. 2. We ordered leukoreduced blood products so as to reduce the CMV load.
3. We maintained the patient s volume status to keep the VAD flows around 5 lpm in an effort to reduce the risk for additional clots. The Abiomed Ventricle is to be checked with every set of vital signs for swirling. The pulsatile swirling motion of the blood through this device pump or ventricle also reduces the risk of clot. Positioning of the external cannula and pump can assure good flow. The company provides a support belt that must be used at all times to prevent cannula kinking and/or pulling. VAD iinfection control measures were initiated in the operating room during the implant and continued throughout his stay. Additionally, we showered the patient when he was on the step down unit. There was extensive use of chux pads, plastic bags, and careful taping to ensure that the entire device, from percutaneous site to console, was covered. NO scissors were used in removing taped plastic after the shower. Please note that Abiomed does not provide instructions as to how to shower patients nor does the company provide any device-protective supplies for showering. We took great care to protect the console from water so as not to cause any water damage to the device. We also put a clear plastic adhesive dressing over the percutaneous lines to reduce the risk of infection. Summary: This case demonstrates the need to continuously evaluate the current plan and escalate the therapy when clinically indicated. Lessons were learned: 1. The patient did not recognize the cardinal signs of a heart attack and therefore did not take action in a timely fashion. By delaying his care, he may have extended the damage to his heart. Although there have been community campaigns to educate the lay population regarding the signs and symptoms of myocardial infarcts, patients continue to ignore symptoms. Obviously, there is an ongoing need for community education. 2. Because the patient did not have any medical history or exposure to heparin in the past, the HIT positive conversion was a surprising finding. The HIT antibody and conversion to argatoban did not occur until after a clot formed in the pump. White clot formation with increasing heparin dose requirements to achieve therapeutic aptt and thrombocytopenia should raise suspicion of HIT and trigger the use of alternative therapies. 3. One surprise we encountered after transplant was that the patient suffered visual changes from multiple exposures to bypass surgery, two CVAs, and post transplant steroid administration. His ability to read small print was greatly compromised. We did not identify this problem until late in his stay. Therefore, we did not work with the patient and family to accommodate this issue until we were preparing for discharge after transplant. We should have had the patient
evaluated for visual deficits well before this time. This did not delay his discharge but caused the patient some stress as he worked with his medication list.