Determining Candidacy for VAD Implantation

History

A male patient in his 30s has a known medical history of nonischemic cardiomyopathy, which was first diagnosed in 2020 with an unclear etiology. He received an implantable cardioverter defibrillator (ICD) after having ventricular tachycardia in 2021. 

The patient has a history of sleep apnea, hypertension and cocaine use. He had a sleeve gastrectomy for treatment of obesity. He was hospitalized for heart failure exacerbation twice. In May 2024, he was treated for cardiogenic shock at an outside hospital.

At a local ventricular assist device (VAD) implanting center in Chicago, he was evaluated for a left ventricular assist device (LVAD). He was deemed too high-risk for LVAD for several reasons, including a history of noncompliance, cocaine use, right ventricular dysfunction, chronic kidney disease and liver dysfunction. He was discharged home on high-dose diuretics and palliative milrinone.

Presentation and examination

In April 2024, the patient presented to Rush’s emergency department and was found to have abnormal labs that included elevated bilirubin (7), ALT (193), AST (99) and creatinine (2.8). He was tachycardic, hypotensive and complaining of abdominal pain suspected to be related to congestion.

He reported being compliant with his diet and medications. A repeat echocardiogram showed an ejection fraction of 10% with severe mitral and tricuspid regurgitation. A right heart catheterization was also performed and showed a cardiac index of 1.8 on milrinone, central venous pressure (CVP) (21), and pulmonary pressures of 49/30/29.

Treatment

The patient was given continuous IV diuretics with a robust urine response. However, he continued to have worsening cardiogenic shock. An intra-aortic balloon pump was inserted in addition to dobutamine, epinephrine and vasopressin.

We launched an LVAD evaluation. There was concern for cardiac cirrhosis given his elevated bilirubin and his CVP remained in the 20s despite extreme diuresis and inotropy. A liver biopsy showed no evidence of fibrosis and the hepatology report showed liver dysfunction, which was consistent with passive venous congestion. There was also concern for the patient’s history of noncompliance and drug use. However, the patient’s drug screen was negative. The patient stated he is now living with his sister and ‘turning his life around.’

The LVAD team confirmed that the patient’s sister was willing for participate in the patient’s care after LVAD. The substance use (SUIT) team was consulted to provide resources and treatment for previous drug use. Social work was engaged to establish caregiver support and a suitable living situation.

Our multidisciplinary team met and decided to implant an LVAD with a plan for a temporary right ventricular assist device given the patient’s known right ventricular dysfunction.

Outcome

The patient was implanted with an HM3 LVAD with temporary RVAD support in early May 2024. During the operation, he required multiple blood products, and his chest was left open with a wound vac; he returned to the OR a couple of days later for chest closure.

His kidney function improved with a Cr from 3 to < 1.0. He had diuresis and was eventually weaned off RVAD support, with the RVAD decannulated two weeks later and weaned off inotropes four days after that. He was discharged home. 

Since being discharged home, the patient has been doing well and continues to follow with the SUIT team. His subsequent drug screenings have been negative.

Analysis

Determining candidacy for VAD implantation is challenging as the patients have both medical and social complexity. Evaluation requires a collaborative process involving many resources throughout the system.

This patient was turned down at another center for being too high-risk medically and socially. Providing patients with the appropriate resources (for example, SUITS and social work), we were able to overcome his psychosocial obstacles. Medical complexity requires a strong medical and surgical team. When patients present in cardiogenic shock, there is a narrow window to operate.