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Off pump implantation of HeartMate III LVAD and closure of patent foramen ovale in patient with HIT

Session Poster Session 4

Speaker Silvia Cesini

Event : Heart Failure 2019

  • Topic : heart failure
  • Sub-topic : Ventricular Assist Devices
  • Session type : Poster Session

Authors : S Cesini (Cambridge,GB), S Bhagra (Cambridge,GB), Y Abu-Omar (Cambridge,GB), P Catarino (Cambridge,GB), S Pettit (Cambridge,GB)

Authors:
S Cesini1 , S Bhagra1 , Y Abu-Omar1 , P Catarino1 , S Pettit1 , 1Papworth Hospital NHS Trust - Cambridge - United Kingdom of Great Britain & Northern Ireland ,

Citation:

A 55 year old male presented to his primary care physician with exertional breathlessness, an irregular pulse and a systolic murmur.  He had no past medical history of note.  He was found to be in atrial fibrillation.  Echocardiography revealed severe mitral regurgitation due to P2 leaflet prolapse and preserved left ventricular systolic function. Coronary angiography was normal.  He was scheduled for mitral valve surgery and was not anti-coagulated given that the anticipated waiting time for surgery was short.

In the week prior to surgery, he presented to his local hospital with an acute ST segment elevation myocardial infarction. Emergency coronary angiography revealed an occluded left anterior descending coronary artery, presumably due to thromboembolism.  He underwent primary angioplasty but only TIMI-2 flow was restored.  The procedure was complicated by cardiogenic shock, with renal and liver injury.  He was stabilized with inotropic and IABP support, then transferred to our hospital for assessment.

He remained IABP dependent, with recurrent pulmonary oedema when augmentation was reduced. Repeat echocardiography showed severe left ventricular systolic dysfunction and severe mitral regurgitation (Fig. 1).  To complicate matters, he developed heparin-induced thrombocytopenia (HIT) and was treated with Argatroban.  Our cardiac surgeons felt that isolated mitral valve surgery would be unacceptably high risk.

We elected to implant a HeartMate III left ventricular assist device (LVAD) as a bridge to heart transplantation.  The procedure was performed without cardiopulmonary bypass in order to avoid administration of heparin.  At the time of surgery, there was evidence of a very small patent foramen ovale (PFO) on trans-oesophageal echocardiography (TOE) but this was not closed. 

The early post-operative period was complicated by progressive arterial desaturation and repeat TOE showed a significant right to left shunt across an enlarged PFO (Fig. 2).  It was clear that the PFO required closure, but we wished to do this without cardiopulmonary bypass.  A mini-thoracotomy was performed and the PFO was closed by careful placement of a suture through the inter-atrial septum from outside the heart under TOE guidance. This resulted in immediate recovery of oxygenation.  The patient made an excellent recovery  from this point forwards.

Conclusions: 1) LVAD may be implanted off-pump without heparin and this strategy is attractive in patients with HIT.  2) Any inter-atrial defect must be closed at the time of LVAD implantation due to the risk of post-operative right to left shunting.  3) It is possible to close a PFO from outside the heart during off-pump LVAD implantation with TOE guidance.

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