https://doi.org/10.53453/ms.2024.3.10
Case report: a seven years journey of advanced heart failure
management including left ventricle assist device implantation and
heart transplantation
Rumbinaitė Eglė
1
, Dovydas Verikas
1,2
, Žūkaitė Gabrielė
3
, Jankauskienė Loreta
1
, Ramūnas Bolys
4
,
Jakuška Povilas
4
, Žaliūnas Remigijus
1
, Benetis Rimantas
4
1
Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences
2
Laboratory for Automation of Cardiovascular Investigation, Cardiology Institute, Lithuanian University of
Health Sciences
3
Faculty of Medicine, Medical Academy, Lithuanian University of Health Sciences
4
Department of Cardiac, thoracic and vascular surgery, Medical Academy, Lithuanian University of Health
Sciences
Abstract
Introduction. The treatment of the advanced heart failure often requires surgical treatment modalities such as left
ventricular assist device implantation and heart transplantation.
Case presentation. This case report highlights the challenges in treating advanced heart failure when long-term
mechanical circulatory support is employed, as well as after heart transplantation. A 59-year-old male with
advanced heart failure due to dilated cardiomyopathy underwent left ventricular assist device implantation in
2016. During the follow-up period, the patient experienced multiple driveline infections and two pump
thromboses. After five years of left ventricular assist device support, a suitable donor was finally found and the
patient underwent a successful heart transplant. However, the postoperative course was complicated by massive
pulmonary embolism, severe COVID-19 infection, recurrent pyelonephritis, and mild episodes of transplant
rejection. One year after heart transplantation, the patient remains in stable condition without any signs of rejection
and with good heart function.
Conclusion. Although heart transplantation remains the gold standard for the treatment of advanced heart failure,
the scarcity of donors and prolonged waiting periods for heart transplantation have resulted in a rise in complicated
cases arising from prolonged left ventricular assist device support. In order to effectively manage advanced heart
failure in its most severe forms, the early diagnosis and accurate treatment strategy of different complications and
comorbidities is crucial.
Keywords: Heart transplantation, left ventricular assistance device, advanced heart failure, COVID-19, driveline
infections
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Medical Sciences 2024 Vol. 12 (2), p. 85-89, https://doi.org/10.53453/ms.2024.3.10
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1. Introduction
The treatment of the advanced heart failure (HF)
often requires surgical treatment modalities such as
left ventricular assist device (LVAD) implantation
and heart transplantation (HT). In this case report,
we describe the seven years advanced HF “journey”
of a 59-year-old male who underwent HeartMate II
(HM II) implantation in October 2016, followed by
HT in August 2021, for the treatment of advanced
HF.
2. Case report
A 59-year-old male presented with rapid onset of
fatigue and shortness of breath in 2015.
Transthoracic echocardiography (TTE) revealed left
ventricle (LV) dilatation, with LV end-diastolic
diameter of 69 mm and severely reduced LV systolic
function (LV ejection fraction [LV EF] 15%) with
diffuse hypokinesis. Invasive angiography showed
no evidence of coronary artery stenoses. The
patient's clinical picture was consistent with dilated
cardiomyopathy, which was confirmed by both TTE
and cardiac magnetic resonance imaging (MRI)
data. One year later, in 2016 the patient was
diagnosed with advanced HF and LVAD - HM II -
was implanted.
Three years later after LVAD implantation, the
patient experienced pump thrombosis (PT) which
was attributed to an inadequate hypocoagulation
regimen and was successfully treated by
administering alteplase. From 2016 to 2021, the
patient was hospitalized multiple times due to
evidence of HM II driveline infection. Despite
ongoing efforts, a suitable donor was not identified,
as the patient's weight had increased to 128 kg,
resulting in a body mass index of 39.07 kg/m2.
In August of 2021, a patient who had undergone
LVAD implantation five years prior was admitted
due to recurrent HM II PT (Figure 1). Heart team
decision was to replace the HM II with an HM3
device. However, after two days a suitable donor
was identified, and the patient underwent a
successful orthotropic HT.
Figure 1. Computer tomography imaging of a
patient with recurrent HeartMate II pump
thrombosis.
During the post-transplantation period, two
myocardial biopsies were conducted which revealed
grade I rejection (with changes being less
pronounced in the second biopsy). It was decided to
maintain higher concentrations of tacrolimus,
staying with the usual doses of other
immunosuppressants. TTE showed – preserved
function of both the left and right ventricles (LV EF
50 %). Because the patient had not received
vaccination against COVID-19 prior to the HT, the
first dose of the vaccine was administered four
weeks after HT and the vaccination course was
completed after rehabilitation.
During the initial 8-month postoperative period
following HT, the patient experienced recurrent
urinary tract infections, including cystitis and
pyelonephritis, with a total of six documented
episodes. The patient was treated with etiotropic
antibiotic therapy utilizing carbapenems with a
treatment duration up to 21 days per episode.
Additionally, i/v immunoglobulin G administration
was employed to correct the secondary
immunodeficiency.
Four months post-HT, the patient was admitted to
the hospital due to dyspnoea at rest. A massive
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pulmonary embolism (PE) and thrombosis of the
right femoral vein were confirmed (Figure 2).
Figure 2. Computer tomography imaging showing
confirmed PE and thrombosis in pulmonary veins.
Figure 3. Computer tomography imaging showing
confirmed severe COVID-19 infection in a patient
following treatment for PE.
The patient received PE treatment, but following
stabilization of the PE, a severe form of COVID-19
infection was diagnosed (Figure 3). Repeated CT
scans showed bilateral reduced airiness,
predominant areas of frosted glass, reticular and
perilobular changes consistent with COVID-19,
with a positive dynamic of PE. Remdesivir and
immune-infected COVID-19 plasma were admi-
nistered, resulting in an improvement in the patient's
condition. A fourth biopsy was performed after
minimizing immunosuppression during COVID-19
treatment, but no rejection was detected. The patient
remains in stable condition without rejection and
infections more than a year post HT.
3. Discussion
Presented case shows how difficult the "journey" of
a patient with advanced HF can be after LVAD
implantation and HT. After LVAD implantation,
frequent driveline infections were observed in our
patient and according to the literature the duration of
mechanical circulatory support represents the major
risk factor [1-3], as our patient lived with HMII for
5 years. Driveline infections usually lead to high
urgency listings for HT [1] as it was in our case,
however, there were no for suitable donor because
of increasing patient weight. The other important
fact is that driveline infections lead to worse post‐
transplantation outcomes and cannot be predicted
before LVAD implantation [1]. Staphylococci have
been identified as the most prevalent pathogens, as
were also observed in our case [4].
LVAD thrombosis is a rare but feared complication
in the course of LVAD treatment [5]. It can result
cerebral and peripheral thromboembolic events,
haemolysis, as well as life-threatening hemo-
dynamic impairments and death [6]. Current options
for the treatment of PT include intravenous heparin,
thrombolytic therapy or pump exchange. Medical
therapy helps us to avoid a reoperative procedure
however, it carries a variably risk for stroke and
major bleeding as well as incomplete thrombus
resolution [7]. Owing to this, many authors suggest
pump exchange as the first-line treatment for PT
[8,9]. However, newer-generation LVADs such as
the HM3 have been shown to have extremely low
rates of PT as in the MOMENTUM 3 trial, the rate
of PT using the HM3 was 1% at 2 years of follow-
up [10]. In our case, PT were predominantly caused
by continuous non-adequate hypocoagulation. For
the first time PT was treated using alteplase, for the
second time – HT was performed.
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Infections are the most relevant complications after
HT and are among the most frequent cause of death
along the post‐transplantation follow-up [11].
Pneumonia (bacterial, Pneumocystis carinii), uri-
nary tract infections (often bacterial), cytomegalo-
virus infections, herpes virus and mycosis frequently
occur [12]. The risk of infection over time may be
modulated by adjusting immunosuppressive
medications. The concept that immunemonitoring
may help to guide immune-suppression is promising
and future studies are needed in this field. The
prognosis in case of SARS-CoV-19 infection is less
favourable than in general population and a survey
of HT centres in Germany showed 33.3 % mortality
[13], in the Italian HT population, mortality was
almost 30 % [14]. Vaccination itself does not
prevent severe forms of COVID-19 as we confirmed
with our case [15]. As it was showed, older age (our
patient underwent HT at age of 65 years), immune-
suppression and lower estimated glomerular filtra-
tion rate are predictors of weakened response to the
vaccination [16].
Deep vein thrombosis and PE are an important and
serious postoperative complications after HT [17].
The incidence of venous thromboembolic events
(VTE) has been reported to vary widely across
studies, ranging from 42 % within 60 days post-HT
to 7 to 12 % [17]. Patients with VTE had longer
hospital stay, higher in-hospital mortality and worse
5-year survival [18]. Early postoperative discharge
from the hospital may be the key to preventing the
development of VTE.
Our patient had a prolonged hospital stay, with an
initial 14-day stay in the ICU due to intensive
delirium, followed by a subsequent 30-day stay in
the Cardiac surgery department as a result of several
episodes of pyelonephritis.
4. Conclusion
The scarcity of donors and prolonged waiting
periods for HT have resulted in a rise in complicated
cases arising from prolonged LVAD support. In
order to effectively manage advanced HF in its most
severe forms, the early diagnosis and accurate
treatment strategy of different complications and
comorbidities is crucial.
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