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CASE ANECDOTES, COMMENTS AND OPINIONS Prolonged left ventricular assist device support (18 months) in refractory ventricular fibrillation Noritsugu Naito, MD,a Osamu Kinoshita, PhD,b and Minoru Ono, MD, PhDb From the aDepartment of Cardiovascular Surgery, Gunma Prefectural Cardiovascular Center, Gunma, Japan; and the bDepartment of Cardiothoracic Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
A 37-year-old man with a diagnosis of dilated cardiomyopathy (DCM), without a previous history of arrhythmia, underwent continuous-flow left ventricular assist device (CFLVAD) implantation in our department. His postoperative course was uneventful except for drive-line infection caused by methicillin-sensitive Staphylococcus aureus (MSSA), which responded well to antibiotics. He was discharged home on Day 87 post-operatively. At time of discharge, electrocardiography showed sinus rhythm. Two months after discharge, he presented to our emergency department with dizziness and difficulty walking. Twelve-lead ECG showed ventricular fibrillation (VF) (Figure 1), which immediately responded to one shock of electrical defibrillation. For further evaluation of VF, he was then admitted to our hospital. During hospitalization, he had multiple episodes of sustained VF. Maintaining sinus rhythm remained a challenge despite initiation of multiple
anti-arrhythmic agents, including bisoprolol, amiodarone and pilsicainide, and optimization of fluid and rotational speed of the CFLVAD pump to avoid a suction event. Because VF became refractory, we decided to manage the patient by VF-Fontan circulation. To obtain higher flow and allow him live a normal life at home, we adhered closely to the following: (i) continued sildenafil citrate to reduce pulmonary vascular resistance (PVR) with sildenafil citrate; (ii) adjustment of the rotational speed and monitoring water balance to prevent LV collapse; and (iii) adaptation of a strict anti-coagulation protocol to prevent clotting in the LV while maintaining prothrombin time/international normalized ratio (PT/INR) at the higher level of 3.0 to 3.5 (in general, for patients with DuraHeart without Fontan circulation, we maintain PT/INR at 2.5 to 3.0). Sildenafil citrate responded well in reducing PVR. Results of the right heart catheter study are shown in Table 1. Currently, he is on once-per-month outpatient follow-up with New York Heart Association (NYHA) Functional Class II and is awaiting heart transplantation. Eighteen months have passed without any complications and hospitalizations after VF became refractory to treatment. Although LVAD may save patients’ lives during VF, it is difficult to obtain hemodynamic stability. The longest duration of CFLVAD support in VF reported so far in the literature is 12 hours,1 whereas a 24-year-old patient was supported by a pulsatile-flow LVAD in VF-Fontan circulation for 15 months before she underwent heart transplantation.2 The patient described herein is currently being supported by CFLVAD with VF status for 418 months. This unique case exemplifies the life-saving hemodynamic
Table 1 Right Heart Catheter Studies Showing Higher CI After Administration of Sildenafil Citrate Even Under VF First admission After Before administration for VF discharge of sildenafil citrate and after LVAD treatment CO (liters/min) 4.4 CI (liters/min/m2) 2.8 CVP (mm Hg) 12 PAP (mm Hg) 40/20 (28) PCWP (mm Hg) 15 PVR (WU) 2.94
Figure 1
2.6 1.6 13 21/15 (17) 9 3.08
3 1.9 13 25/12 (17) 9 2.67
CI, cardiac index; CO, cardiac output; CVP, central venous pressure; PCWP, pulmonary capillary wedge pressure; PVR, pulmonary vascular resistance; RAP, right atrial pressure; WU, Wood units.
Twelve-lead electrocardiogram showing VF.
1053-2498/$ - see front matter r 2014 International Society for Heart and Lung Transplantation. All rights reserved. http://dx.doi.org/10.1016/j.healun.2014.04.012
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The Journal of Heart and Lung Transplantation, Vol ], No ], Month ]]]]
benefit and preservation of quality of life with CFLVAD, even with refractory ventricular arrhythmia.
Disclosure statement The authors have no conflicts of interest to disclose.
References 1. Sims DB, Rosner G, Uriel N, et al. Twelve hours of sustained ventricular fibrillation supported by a continuous-flow left ventricular assist device. Pacing Clin Electrophysiol 2012;35:e144-8. 2. Nishimura M, Ogiwara M, Ishikawa M, et al. Fifteen-month circulatory support for sustained ventricular fibrillation by left ventricular assist device. J Thorac Cardiovasc Surg 2003;126:1190-2.
CASE ANECDOTES, COMMENTS AND OPINIONS Prolonged left ventricular assist device support (18 months) in refractory ventricular fibrillation Noritsugu Naito, MD,a Osamu Kinoshita, PhD,b and Minoru Ono, MD, PhDb From the aDepartment of Cardiovascular Surgery, Gunma Prefectural Cardiovascular Center, Gunma, Japan; and the bDepartment of Cardiothoracic Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
A 37-year-old man with a diagnosis of dilated cardiomyopathy (DCM), without a previous history of arrhythmia, underwent continuous-flow left ventricular assist device (CFLVAD) implantation in our department. His postoperative course was uneventful except for drive-line infection caused by methicillin-sensitive Staphylococcus aureus (MSSA), which responded well to antibiotics. He was discharged home on Day 87 post-operatively. At time of discharge, electrocardiography showed sinus rhythm. Two months after discharge, he presented to our emergency department with dizziness and difficulty walking. Twelve-lead ECG showed ventricular fibrillation (VF) (Figure 1), which immediately responded to one shock of electrical defibrillation. For further evaluation of VF, he was then admitted to our hospital. During hospitalization, he had multiple episodes of sustained VF. Maintaining sinus rhythm remained a challenge despite initiation of multiple
anti-arrhythmic agents, including bisoprolol, amiodarone and pilsicainide, and optimization of fluid and rotational speed of the CFLVAD pump to avoid a suction event. Because VF became refractory, we decided to manage the patient by VF-Fontan circulation. To obtain higher flow and allow him live a normal life at home, we adhered closely to the following: (i) continued sildenafil citrate to reduce pulmonary vascular resistance (PVR) with sildenafil citrate; (ii) adjustment of the rotational speed and monitoring water balance to prevent LV collapse; and (iii) adaptation of a strict anti-coagulation protocol to prevent clotting in the LV while maintaining prothrombin time/international normalized ratio (PT/INR) at the higher level of 3.0 to 3.5 (in general, for patients with DuraHeart without Fontan circulation, we maintain PT/INR at 2.5 to 3.0). Sildenafil citrate responded well in reducing PVR. Results of the right heart catheter study are shown in Table 1. Currently, he is on once-per-month outpatient follow-up with New York Heart Association (NYHA) Functional Class II and is awaiting heart transplantation. Eighteen months have passed without any complications and hospitalizations after VF became refractory to treatment. Although LVAD may save patients’ lives during VF, it is difficult to obtain hemodynamic stability. The longest duration of CFLVAD support in VF reported so far in the literature is 12 hours,1 whereas a 24-year-old patient was supported by a pulsatile-flow LVAD in VF-Fontan circulation for 15 months before she underwent heart transplantation.2 The patient described herein is currently being supported by CFLVAD with VF status for 418 months. This unique case exemplifies the life-saving hemodynamic
Table 1 Right Heart Catheter Studies Showing Higher CI After Administration of Sildenafil Citrate Even Under VF First admission After Before administration for VF discharge of sildenafil citrate and after LVAD treatment CO (liters/min) 4.4 CI (liters/min/m2) 2.8 CVP (mm Hg) 12 PAP (mm Hg) 40/20 (28) PCWP (mm Hg) 15 PVR (WU) 2.94
Figure 1
2.6 1.6 13 21/15 (17) 9 3.08
3 1.9 13 25/12 (17) 9 2.67
CI, cardiac index; CO, cardiac output; CVP, central venous pressure; PCWP, pulmonary capillary wedge pressure; PVR, pulmonary vascular resistance; RAP, right atrial pressure; WU, Wood units.
Twelve-lead electrocardiogram showing VF.
1053-2498/$ - see front matter r 2014 International Society for Heart and Lung Transplantation. All rights reserved. http://dx.doi.org/10.1016/j.healun.2014.04.012
2
The Journal of Heart and Lung Transplantation, Vol ], No ], Month ]]]]
benefit and preservation of quality of life with CFLVAD, even with refractory ventricular arrhythmia.
Disclosure statement The authors have no conflicts of interest to disclose.
References 1. Sims DB, Rosner G, Uriel N, et al. Twelve hours of sustained ventricular fibrillation supported by a continuous-flow left ventricular assist device. Pacing Clin Electrophysiol 2012;35:e144-8. 2. Nishimura M, Ogiwara M, Ishikawa M, et al. Fifteen-month circulatory support for sustained ventricular fibrillation by left ventricular assist device. J Thorac Cardiovasc Surg 2003;126:1190-2.
