(195) Unexpected Twist: Intestinal Ischemia in an LVAD Recipient

Introduction: Left Ventricular Assist Devices have become the standard of care for circulatory support in end-stage or refractory heart failure as either bridge to transplantation or destination therapy. Although infections, bleeding, thrombosis and renal dysfunction are known complications, intestinal ischemia has been rarely reported. This case discusses the poor characterization and delayed presentation of intestinal ischemia in a patient with LVAD and its impact on mortality and morbidity.

Description: A 59-year-old female with history of biventricular heart failure (EF=15%) secondary to ischemic cardiomyopathy underwent LVAD implantation with Heartmate 3 on 09/01/2021. Her comorbidities included hypertension, type 2 diabetes mellitus, hypercholesterolemia, hyperthyroidism, Klebsiella aerogenes related driveline infection, acute kidney injury (AKI) with need of renal replacement therapy (RRT) and gastrointestinal bleeding. She presented to emergency department with worsening fatigue and weakness for past 10 days with cough, abdominal discomfort and dark stool. She was drowsy, had bilateral pedal edema, soft but protuberant abdomen. She was found to have WBC -11600, Hb-10.0, INR-1.4, Platelet-107000, lactate-3.1, BUN/Cr-60/3.5, AST/ALT-10/16. She underwent CT angiography of abdomen that revealed infarcted bowel involving the distal ileum, the ascending colon and proximal transverse colon with few segments of necrotic bowel wall associated with extra and intraperitoneal air. The patient underwent emergency laparotomy, resection of terminal ileum to transverse colon and subsequent end ileostomy.

Discussion: Intestinal ischemia, a rare but severe GI complication after LVAD or cardiac surgery, may result from decreased splanchnic perfusion due to low cardiac output, vasopressor use, hypotension, or embolic events. Diagnosis is difficult due to nonspecific symptoms, leading to delays and worsened ischemia. Lactic acidosis, a sign of mesenteric ischemia, is inconsistent, causing diagnostic delays. Identifying at-risk patients, maintaining high suspicion, and having a low threshold for diagnostic studies are critical for early detection and treatment.