Assessment and Management of Heart Failure After Left Ventricular Assist Device Implantation
Case Presentation: A 56-year-old man with a history of ischemic cardiomyopathy and New York Heart Association functional class IV heart failure (HF) requiring intravenous inotropic therapy underwent uncomplicated implantation of a continuous-flow left ventricular assist device (LVAD) as bridge to heart transplantation (HT). The patient was weaned off inotropic support during the first week after surgery and had progressive improvement in functional status. He was discharged home on maintenance antithrombotic therapy with aspirin 325 mg once daily and warfarin targeted to an international normalized ratio of 2.0 to 3.0. Eight weeks after LVAD implantation, he developed progressive dyspnea on exertion, recurrent pedal edema, and a 7-pound weight gain. Physical examination revealed conjunctival pallor, a palpable carotid pulse, jugular venous pressure of 14 cm H2O, and 2+ pitting edema bilaterally. A rapid and targeted assessment of recurrent HF is essential in this LVAD patient because of multiple, potentially life-threatening causes that necessitate divergent treatments.
LVAD Therapy in Advanced HF
The US Food and Drug Administration first approved implantable LVADs as a bridge to transplantation in 1994.1 Although HT remains the gold standard therapy for selected patients with end-stage HF, the stable donor base of <2500 hearts per year in North America limits its widespread applicability.2 The landmark Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) trial established the first-generation, pulsatile-flow HeartMate (HM) XVE LVAD as a viable, life-prolonging treatment in patients who were not candidates for HT, a strategy known as destination therapy (DT). However, survival 2 years after implantation was still only 23%, in part because of the high rates of mechanical pump failure.
The advent of continuous-flow LVADs has provided a more durable long-term treatment that improves quality of life and survival.3 The continuous-flow HM II LVAD has a markedly lower rate of device …