Cardiogenic shock treated with multiple mechanical circulatory support devices

Autor: J. Dutton, Andre R. Simon, Nicholas Lees, E. Recchia, M. Morosin, M. Giunta, M. Scaramuzzi
Rok vydání: 2019
Předmět:
Zdroj: Journal of Cardiothoracic and Vascular Anesthesia. 33:S162
ISSN: 1053-0770
DOI: 10.1053/j.jvca.2019.07.044
Popis: Introduction A 62-year-old man was admitted to a local hospital for heart failure. An echo showed severe biventricular dysfunction, severe LV dilatation and a large and mobile finger-like aspect thrombus extending from septum, across apex and posterior wall. He presented severe instability and therefore was transferred to our centre for further management. On arrival, he suffered electrical VT storm and a VA-ECMO was inserted. At this point, heart catheterization and angiography were considered unsafe. After multidisciplinary discussion, a Levitronix LVAD with filters was inserted as bridge to decision. Due to rapid RV function deterioration an intraoperative decision was made to add an RVAD with an oxygenator. He was inserted on the transplant list, but unclear capacity to cope with treatment and significant psychiatric issues emerged after family discussion. Refractory VF developed which lead to a fully thrombosed LV. In the evaluation for candidacy, a total artificial heart (TAH) was implanted. After the procedure, the patient experienced a stroke leading to left hemiplegia and fluctuating level of consciousness. After a period of relative clinical stability, the patient developed a catastrophic intestinal bleeding. Given the multiple complications developed during the ITU stay (renal failure, multi-drug resistant infections, neurological impairment and unsuitability for transplant) a laparotomy appeared not to be in the patient's best interest. After family discussion, palliation was commenced. Native heart histology revealed extensive multifocal sub-endocardial myocardial infarction involving the LV. Right and left coronary arteries showed significant atherosclerotic disease. Discussion Over recent years, mechanical circulatory support devices have revolutionized cardiovascular therapeutics. In the present case, the initial issue was the severe haemodynamic instability condition in which the patient presented, which lead to an unwanted incomplete assessment of the underlying disease. A multidisciplinary discussion was made about further management after VA-ECMO insertion: in order to discuss with the patient and assess candidacy to transplant, no other ways appeared to be reasonable than implanting a Levitronix, which could have allowed to awake the patient. As soon as the medical team was able to discuss with the patient and the family about further management, neuropsychiatric issues arose, delaying the decision to a definitive insertion of the patient to the transplant list. During this assessment period, massive LV thrombus developed rising the issue of Levitronix occlusion, leading to two main life-treating options: heart transplant or total artificial heart. This case shows how complex the management of a severe heart failure with cardiogenic shock may be and how different types of mechanical circulatory support devices may be required for similar severity of the original disease depending on the phase of the treatment and the comorbidities.
Databáze: OpenAIRE
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