Cardiovascular Journal of Africa: Vol 29 No 3 (May/Junel 2018)

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 3, May/June 2018

AFRICA

Second, we expected recovery of the stunned myocardium

after the acute myocardial infarction. Therefore, we abandoned

use of the most advanced VADs, such as the HeartMate II

HeartWare,

in which cannulation of the ventricular apex for

drainage is necessary. We rather used the Levitronix

because we

could cannulate the vent tube on the right superior pulmonary

vein (Fig. 1) instead of the ventricular apex. The apical location

would make surgical repair much more difficult, assuming that

the viable but stunned myocardium could recover and the VAD

could be withdrawn. We used a Snell-tie retention suture to

securely fix both the vent and perfusion tubes. This also enabled

a simple and quick closure of the cannulation wounds, which

would facilitate the withdrawal procedure.

Third, although various kinds of VADs are available in

Taiwan, not all are reimbursed by the National Health Insurance.

In Taiwan, the Levitronix

costs approximately US$12 000, while

the HeartMate II or HeartWare costs over US$170 000. Only

the Levitronix

is covered by the National Health Insurance.

Therefore, we opted to use Levitronix

instead of the HeartMate

II or HeartWare because of economic considerations.

However, complications such as coagulopathy,

thromboembolisation and mechanical failure are common

with VAD use. Thromboembolisation after VAD implantation

resulting in cerebrovascular events is devastating.

There is no

optimal treatment for stroke in patients implanted with a VAD.

Supportive anticoagulation therapy rather than thrombolytic

therapy, which is potentially associated with greater risk of

haemorrhagic events after major surgery, is obviously essential

treatment in this population.

In our current protocol for heparinisation therapy, we prefer

to maintain the ACT at approximately 160 s to avoid major,

spontaneous bleeding disasters. If there are complications such

as surgical bleeding or symptoms of coagulopathy (e.g. bloody

sputum, massive gastrointestinal bleeding and large subcutaneous

ecchymoses), we taper the heparin dose and maintain the ACT at

approximately 140 s. If VAD-related thrombosis is suspected, we

aim to prolong the ACT at 180–250 s.

In the present case, the pre-VAD CT scan showed no cerebral

ischaemia, but the post-VADCT scan showed acute left cerebellar

infarction (Fig. 2). Judging by the chronology of events, the

stroke event was suspected to be due to cardiopulmonary

resuscitation rather than VAD-related embolisation. This is

because a stroke event cannot usually be detected in the acute

stage (especially within 24 hours) on CT. The only imaging

examination to confirm acute-stage stroke is MRI, which was

not practicable for this patient. Therefore we maintained the

ACT at 140–160 s rather than > 180 s. Of course, post-infarct

haemorrhage is another big concern. Eventually, we did not

maintain the ACT at

140 s because the CT scan showed no

post-infarct haemorrhage.

In this case, the patient suffered from concomitant fulminant

myocarditis and acute cerebellar infarction. It is useful to

stabilise the infarct without ischaemic expansion or haemorrhagic

transformation by maintaining the ACT at 140–160 s throughout

the course. Our experience in this case indicates that short-term

VAD use would be the first choice for mechanical circulatory

support, not only because of much shorter surgery time but also

cost-effectiveness, especially in patients with unconfirmed brain

damage.

Conclusion

Levitronix

VAD provides excellent short-term cardiac

mechanical support for patients with severe symptomatic

cerebrovascular disease. It offers patients an option, a bridge to

recovery, that is not only cost-effective but also decreases cardiac

trauma during potential removal.

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