Cardiovascular Journal of Africa: Vol 27 No 4 (July/August 2016)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 27, No 4, July/August 2016 e14 AFRICA
Case Report
Successful continuous-flow left ventricular assist device
implantation with adjuvant tricuspid valve repair for
advanced heart failure
Chih-Hsien Lee, Jeng Wei
Abstract
The prevalence of end-stage heart failure (HF) is on the
increase, however, the availability of donor hearts remains
limited. Left ventricular assist devices (LVADs) are increas-
ingly being used for treating patients with end-stage HF.
LVADs are not only used as a bridge to transplantation but
also as a destination therapy. HeartMate II, a new-generation,
continuous-flow LVAD (cf-LVAD), is currently an established
treatment option for patients with HF. Technological progress
and increasing implantation of cf-LVADs have significantly
improved survival in patients with end-stage HF. Here we
report a case of a patient with end-stage HF who was success-
fully supported using cf-LVAD implantation with adjuvant
tricuspid valve repair in a general district hospital.
Keywords: cf-LVAD, end-stage heart failure, HeartMate II
Submitted 19/9/15, accepted 16/3/16
Published online 12/4/16
Cardiovasc J Afr 2016; 27: e14–e16
DOI: 10.5830/CVJA-2016-034
HeartMate II is anew-generation, continuous-flow left ventricular
assist device (cf-LVAD, Thoratec, Pleasanton, CA, USA) used as
a bridge to transplantation (BTT) and as a destination therapy
(DT) in patients with end-stage heart failure (HF).1 Applying
continuous-flow technology to mechanical circulatory support
systems has revolutionised the treatment of end-stage HF.
The use of implantable mechanical circulatory support
devices, such as cf-LVAD, has increased in recent years.2 Safer
long-term cf-LVAD support has been achieved because of
improved outcomes.1 Patients supported for BTT or DT
using cf-LVADs have an overall reduction in life-threatening
complications and have prolonged survival time, with an active
lifestyle and an acceptable quality of life. Cardiac transplant
recipients can safely wait for extended periods while their status
at transplant is optimised, aiding post-transplant survival. In
this case report, we describe a patient with end-stage HF who
was successfully supported using cf-LVAD implantation with
adjuvant tricuspid valve repair.
Case report
A 39-year-old man was admitted to our hospital because of
deteriorating heart function despite maximal medical treatment.
He had a body surface area of 1.88 m2, had suffered from
advanced HF following dilated cardiomyopathy, and had been
waiting for a heart transplant for four years. In addition, he had
diabetes mellitus requiring insulin control. On examination, he
exhibited bilateral grade IV pitting oedema of the lower limbs
with bilateral pleural effusion and ascites.
Laboratory tests showed a total bilirubin level of 6.2 mg/dl,
aspartate aminotransferase level of 109 U/l, and blood creatinine
level of 1.8 mg/dl. Echocardiography revealed a left ventricular
(LV) diastolic diameter of 67 mm, LV systolic diameter of
58 mm, and ejection fraction of 19% with severe tricuspid
regurgitation (TR).
A pulmonary artery catheter was inserted to measure
pulmonary artery systolic pressure, pulmonary capillary wedge
pressure, central venous pressure and cardiac index, which
were found to be 34, 50 and 36 mmHg, and 0.5 l/min/m 2,
respectively. This facilitated optimising the use of dobutamine
and dopamine to decrease the right ventricular (RV) afterload
while maintaining ventricular contractility. An intra-aortic
balloon pump was inserted at the same time because the
urine output had decreased. Furosemide was continuously
administered to obtain an adequate urine output and to decrease
central venous pressure to < 24 mmHg. Right ventricular failure
(RVF) is common after cf-LVAD implantation and is a leading
cause of morbidity and death after cf-LVAD implantation.
Five days after admission, tricuspid valve repair was performed
using the de Vega annuloplasty procedure under anaesthesia.
HeartMate II was implanted under cardiopulmonary bypass.
The alignment of the mitral valve and inflow cannula was
checked using transoesophageal echocardiography.
Initial pump flow was at 6 000 rpm, and we gently needle-
punctured the cf-LVAD outflow tract to assist in de-airing the
intracardiac air bubbles. The needle and clamp were removed,
cardiopulmonary bypass was terminated, and the pump speed
Department of Cardiac Surgery, Tungs’Taichung Metro-
Harbor Hospital; Department of Biological Science and
Technology, National Chiao-Tung University; Department
of Surgery, National Defense Medical Centre, Taiwan
Chih-Hsien Lee, MD,
Heart Centre, Cheng Hsin General Hospital, Taiwan
Jeng Wei, MD, MSD