Associate Professor of Anesthesiology & Perioperative Medicine and Surgery University of Massachusetts Medical School, United States
Introduction: Left ventricular assist devices (LVADs) are essential tools in managing end-stage heart failure, often bridging to transplant or serving as a destination therapy. Complications such as ventricular tachycardia (VT) and aortic valve disorders can impact outcomes. This case report highlights unique challenges in managing refractory VT in an LVAD patient with Amiodarone toxicity and severe aortic regurgitation.
Description: The patient was a 60-year-old male with a history of ischemic cardiomyopathy and a HeartMate 3 LVAD placed three years ago (bridge to transplant) who presented to the hospital with generalized weakness. He had been on amiodarone therapy, leading to the development of thyroiditis. Soon after admission he developed VT, which was shocked by his ICD. He was started on medical management for thyroid storm and referred for urgent thyroidectomy. Despite this, VT persisted and he was started on a lidocaine infusion and transferred to the ICU. A transthoracic echocardiogram (TTE) was not feasible due to poor windows, but the VAD appeared to be functioning normally. An arterial line and PA catheter were placed. Initial readings indicated poor cardiac output by thermodilution (TD) and Fick, and elevated right-sided pressures. The patient was placed on Milrinone and inhaled epoprostenol for RV support. The next day, he was intubated due to worsening hypoxia and altered mental status. A TEE revealed new severe, continuous aortic regurgitation. The patient experienced refractory VT with multiple ICD shocks. Procainamide was added and he was taken emergently to the EP lab for ablation. The EP team was able to ablate the VT; however, severely worsening RV dysfunction was noted. Shortly after the procedure, his VAD alarmed for low flow with a non-perfusing MAP. CPR was initiated, but the patient ultimately passed away after a prolonged resuscitation.
Discussion: AI and VT are known complications that can develop during LVAD support and can severely compromise forward flow, leading to a reduction in cardiac output despite normal LVAD flows. This can further result in inadequate LV offloading, elevated wedge pressure, pulmonary hypertension, and RV dysfunction. This case emphasizes the importance of vigilant monitoring and early intervention in managing complications of LVAD therapy.
