Interact CardioVasc Thorac Surg 2009;9:919-920. doi:10.1510/icvts.2009.215244
© 2009 European Association of Cardio-Thoracic Surgery
Case report - Assisted circulation |
Left ventricular assist device placement in a patient with end-stage heart failure and human immunodeficiency virus
David S. Fienoa,b,
Lawrence S. Czera,b,
Ernst R. Schwarza,b and
Sinan Simsira,b*
a Cedars-Sinai Medical Center, Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
b Cedars-Sinai Medical Center, Division of Cardiothoracic Surgery, Department of Surgery, 8700 Beverly Boulevard, Suite 6215, Los Angeles, CA 91604, USA
Received 23 June 2009;
received in revised form 7 August 2009;
accepted 10 August 2009
*Corresponding author. Tel.: +1-310-423-3851; fax: +1-310-423-0127.
E-mail address: simsirs{at}cshs.org (S. Simsir).
 |
Abstract
|
|---|
Left ventricular assist device (LVAD) insertion has been used more frequently within the recent years either as a bridge to transplant or as destination therapy in patients with advanced heart failure who fail medical therapy. We present a report of a 60-year-old male patient with end-stage heart failure and cardiomyopathy with a history of human immunodeficiency virus (HIV) infection who underwent LVAD placement as destination therapy. To our knowledge, LVAD placement in this fashion has not been reported previously. Following LVAD implantation, the patient recovered during the course of five weeks and was discharged home from the hospital in good condition. The patient was alive and free of any activity limitations sixteen months postoperatively. We conclude that LVAD placement for end-stage heart failure may be a feasible option as destination therapy in patients with HIV.
Key Words: Left ventricular assist device; Human immunodeficiency virus; Heart failure
|
1. Case report
|
|---|
In this report, we describe a patient with heart failure and a history of human immunodeficiency virus (HIV) disease who was referred for consideration of left ventricular assist device (LVAD) and subsequently underwent successful surgical placement with excellent clinical results.
The patient was a 60-year-old male who presented to the hospital complaining of disabling shortness of breath and fatigue. The patient had New York Heart Association (NYHA) Class IV end-stage heart failure secondary to cardiomyopathy, non-ischemic in etiology, and had suffered with progressively worsening exacerbations of chronic heart failure symptoms for at least the last five years. The patient was compliant and was carefully followed by multiple subspecialists. The patient had a history of gout, depression, and one episode of Pneumocystis jiroveci pneumonia in the past that was resolved. The patient was taking appropriate medications for heart failure (including ACE-inhibitor, beta blocker, digoxin, diuretics, aldosterone antagonists and coumadin, goal INR 2-3) as well as highly active antiretroviral therapy as an out-patient.
Prior to admission, a left heart catheterization had revealed no significant obstructive coronary artery disease and a biventricular pacemaker with defibrillator was placed. The device was placed because the patient had severe left ventricular dysfunction [ejection fraction (EF) 12%] that did not improve with medical therapy as well as a left bundle branch QRS morphology on surface electrocardiogram. Endomyocardial biopsy revealed patchy fibrosis throughout the myocardium. At the time of admission, he was noted to be short of breath, tired, systolic blood pressure of  80 mmHg, and pale at rest with ongoing symptoms despite medical therapy. Further evaluation revealed brain natriuretic peptide level of 1890 pg/ml, sodium 123 mEq/l, creatinine 1.3 mg/dl, INR 2.3, CD4 count of 180, and undetectable HIV viral load. Echocardio-graphic evaluation revealed an EF of 10%, severe global ventricular dysfunction, severe mitral regurgitation, pulmonary artery systolic pressure of 53 mmHg, patent foramen ovale, and severe four-chamber cardiac enlargement. Right heart catheterization revealed the following: mean right atrial pressure 18 mmHg, pulmonary artery pressure 40/18, mean pulmonary artery capillary wedge pressure 18, cardiac output 4.0 l/min, and cardiac index 1.8 l/min/m2. The patient was placed on continuous intravenous infusion of dobutamine at a rate of 2 µg/kg/min with improvement of systolic blood pressure to 90–100 mmHg but without significant improvement in symptoms or cardiac index.
Accordingly, the patient was seen and evaluated for possible cardiac replacement therapy. Because of his history of immunosuppression due to HIV with an opportunistic infection, it was decided that he may not be a candidate for cardiac transplantation. The patient underwent placement of a destination ventricular assist device (Thoratec HeartMate XVE, Pleasanton, CA) through a median sternotomy approach. The patent foramen ovale was repaired during the operation. Right heart catheterization postoperatively revealed mean right atrial pressure of 10 mmHg, pulmonary artery pressure of 35/16 mmHg and VAD flow between 4.9 and 5.7 l/min. The patient was extubated on postoperative day three and remained in the intensive care unit for three weeks due to delirium. It was noted that the patient had clinical and laboratory findings consistent with heparin induced thrombocytopenia. The patient was fully mobilized and discharged to home from the hospital in hemodynamically stable condition without any limitations in modest activity at five weeks after LVAD implantation. At 16 months postoperatively, the patient was alive, free of any activity limitations, and had even become a spokesperson for our LVAD program. Unfortunately, at that time, the patient had a sudden, unexpected LVAD pump malfunction that required hand-pumping, hospital admission, and attempt to stabilization with a pneumatic controller. It was determined that the pump failed due to fluid ingress into the venting port in the right upper quadrant. The patient was stabilized somewhat using the external pneumatic console in accordance with previous such experience. The status of heparin-induced thrombocytopenia was further studied prior to pump change out. Five days later, the patient had acute change in mental status, required intubation and ICU transfer, and echocardiography revealed severe biventricular failure. At that time, the patient was emergently taken to the operating room for pump exchange. Intraoperatively, there was severe cardiac depression along with worsening end-organ failure. Despite emergent cardiopulmonary bypass and implantation of a new pump, the patient remained severely acidotic without adequate circulation due to multiorgan system failure and expired.
|
2. Discussion
|
|---|
Cardiac abnormalities occur in approximately one in four HIV-positive patients [1]. The most common cardiac conditions associated with HIV include pericarditis, myocarditis, dilated cardiomyopathy, cardiac tumors, and valvular disease. For some patients, HIV itself can lead to end-stage heart failure, debilitating symptoms, and death. Other patients, however, do not suffer cardiac sequelae directly due to their HIV disease but rather due to progression of other processes, such as coronary artery disease and non-ischemic cardiomyopathies, that eventually lead to heart failure. Because transplantation requires immunosuppression, HIV has traditionally been viewed as a relative contraindication for solid organ transplant and therapy has been predominately supportive for HIV-positive patients with end-stage heart failure as the post-transplant therapy could potentially worsen the immune deficiency [2].
In 2003, there was a report of good 24-month follow-up in one HIV-positive patient with ischemic cardiomyopathy who had undergone successful transplantation [3]. A call was made to initiate transplantation programs at major centers for HIV-positive patients. While encouraging, the long-term outcomes in these patients are unknown. Our patient had already suffered an opportunistic infection related to his HIV disease and thus did not qualify for immunosuppression post-transplant. This allowed the opportunity to consider other options for end-stage heart failure and, in this case, LVAD placement was successful and provided an excellent clinical outcome for this patient.
To our knowledge, this is the first published report of LVAD placement in a patient with HIV. We conclude that LVAD placement for end-stage heart failure may be a feasible option in patients with HIV disease and end-stage heart failure.
|
References
|
|---|
- Jahangiri B, Haddad H. Cardiac transplantation in HIV-positive patients: are we there yet? J Heart Lung Transplant 2007;26:103–107.[CrossRef][Medline]
- Bisleri G, Morgan JA, Deng MC, Mancini DM, Mehmet CO. Should HIV-positive recipients undergo heart transplantation? J Thorac Cardiovasc Surg 2003;126:1639–1640.[Free Full Text]
- Calabrese LH, Albrecht M, Young J, McCarthy P, Haug M, Jarcho J, Zackin R. Successful cardiac transplantation in an HIV-1-infected patient with advanced disease. N Engl J Med 2003;348:2323–2328.[Free Full Text]
|
|
Top
Abstract
1. Case report