Postcardiotomy
Shock Patient Transported While on BVS® Receives Heart
Transplant
A 53-year-old male with a history of coronary artery disease,
chest pain, arrhythmias and hypertension underwent a routine
diagnostic cardiac catheterization which revealed a 50%
occlusion of the LAD, 70% occlusion of the secondary diagonal
lesion and a 40-50% occlusion of the mid-circumflex. At
that time, angioplasty was performed and the patient was
discharged to home. Two weeks later, the patient returned
to the hospital with recurring chest pain, a stent was
placed and the patient was discharged. Two weeks later,
the patient again presented to the hospital with chest
where a repeat cardiac catheterization revealed a dramatic
worsening of his disease. The patient underwent cornoary
artery bypass surgery the next day. During the operative
course, the patient was unable to be weaned from cardio-pulmonary
bypass and an ABIOMED BVS 5000 was implanted. The patient
was then transported via mobile ICU to a regional cardiac
transplant center. Four days later the decision was made
to place the patient on the cardiac transplant list. He
was transitioned to a longer term cardiac assist device
at that time. Two months later the patient underwent a
cardiac transplant, he was discharged to home two weeks
later.
History
A 53-year-old male with a history of CAD, unstable
angina, VF, HTN and hypercholesterolemia underwent
a diagnostic cardiac catheterization which revealed
a 50% LAD, 70% secondary diagonal lesion and a 40-50%
mid-circumflex lesion and a normal RCA. At that time,
angioplasty was performed to the two diagonal lesions
and the patient was discharged. Two weeks later, the
patient returned to the hospital with angina and a
stent was placed to the LAD. Two weeks later, the
patient again presented to the hospital with angina
where a repeat cardiac catheterization revealed a
dramatic worsening of his disease, with a 90% LAD,
70-80% LM, 80% circumflex, 80% diagonal, moderate
RCA disease and an EF of 35%. The patient was scheduled
for surgery the next day. The patient remained hemodynamically
stable with a HR of 86, BP of 136/68, and a SaO2 of
96%.
Operative Summary
A CABG x 4 was performed without complication. However,
within 40 minutes of arrival in the ICU, the patient
went into refractory ventricular fibrillation, requiring
internal cardiac massage. He was taken to the OR and
placed emergently on CPB within 45 minutes, wherein
his LAD was regrafted. The patient failed to wean
from bypass despite maximal inotropic support. The
ABIOMED BVS LVAD was implanted with a 32 Fr. atrial
cannula into the SPV and a 10 mm Hemashield cannula
was anastomosed to the ascending aorta. The patient
was successfully weaned from CPB, with an LVAD flow
rate of 5.7 L/min and was transferred to the ICU in
stable hemodynamic condition.
Post-Operative
On POD 1, the patient was transported via mobile ICU
to the regional cardiac transplant center for further
evaluation. On POD 4, there was still no evidence
of myocardial recovery and the patient was neurologically
intact. A decision was made to transfer the patient
to a long-term implantable LVAS. Approximately two
months later, a suitable donor heart became available,
and a successful orthotopic heart transplant was performed
without complication. The patient was discharged home
two weeks later, and has returned to normal daily
activities.
Patient Data
Indication for Use: Post-cardiotomy cardiogenic shock
Type of support: LVAD
Age: 53 Sex: M Weight: 78.2 kg Height: 183 cm BSA:
2.0 m2
Surgical Data
Surgical Procedure: CABG x 4 with subsequent emergent
CABG x1 regrafting of LAD
Total CPB time: 5 Hours
Attempts to wean CPB: 1
Time between CPB and LVAD: 45 minutes
IABP prior to LVAD: No
Cannulation: Right SPV - 32 F. atrial. Ascending Aorta
- 10 mm. Hemashield
Patient Hemodynamics
|
Pre Implant |
On BVS Support |
| MAP: |
66 |
78 |
| RAP: |
14 |
15 |
| PAP: |
40/19 |
21/14 |
| CI: |
1.6 |
2.4 |
| EF: |
10% |
N/A |
| L/M: |
N/A |
4.5-5.2 |
Organ Function on BVS Support
Liver: Normal (SGOT 22, SGPT 28)
Kidney: Creatinine 1.3, BUN 14
Anticoagulation Therapy
Titrated heparin initiation time: 9 hours post BVS
implant
Chest tube drainage: 60cc/hr avg.
ACT range: 150-220 seconds
|
