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Case Presentation
A 35-year-old man presented to the emergency department with a chief complaint of progressive dyspnea, fatigue, and leg edema for past 2 weeks. He also reported a viral prodrome a few weeks ago. On arrival, he was found to be tachycardic and hypotensive. Patient denied any past medical or surgical history. He further denied any history of smoking, alcohol, or illicit drug use. The patient has no family history of cardiomyopathy.
The patient’s transthoracic echocardiogram showed biventricular dysfunction with severely reduced left ventricular (LV) function of 10% with multiple LV thrombi. He was started on norepinephrine and inotropic support with dobutamine. He was also started on intravenous heparin for LV thrombus. He underwent invasive hemodynamics with right heart catheterization, which showed a pulmonary capillary wedge pressure of 25 mmHg, cardiac output of 4.4 CO Liter/min, and cardiac index of 2.0 CI L/min/m2. Left heart catheterization showed patent coronaries. Cardiac magnetic resonance imaging showed mid-wall late gadolinium enhancement at basal interventricular septal segments. Broad-spectrum workup for dilated cardiomyopathy included normal thyroid function test, negative HIV panel, negative Lyme panel, negative antinuclear antibodies, and respiratory viral panel.
The patient’s hospital course was complicated by progressive hypotension and tachycardia requiring intra-aortic balloon pump (IABP) placement. Despite being on an inotrope, vasopressor, and IABP, he remained tenuous and in a persistent low-output state refractory to medical treatment. He underwent left ventricular thrombectomy and implantation of an intracorporal LV assist device (LVAD; HeartMate 3). After LVAD implant, he continued to improve. Guideline-directed heart failure therapy was introduced, and he was eventually discharged in a stable condition.
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KEY POINTS
Durable mechanical circulatory support is used in advance heart failure management as a bridge to transplant, bridge to destination, and bridge to recovery.
Several types of left, right, and biventricular devices are used to provide mechanical pumping to improve cardiac output.
The HeartMate 3 device is the most common LVAD currently in use. These devices need to be meticulously managed and require frequent follow-up visits. They are associated with complications such as bleeding, infection, and strokes.
Physical knowledge about these devices and their functions, mechanism, and complications is integral in optimizing these patients.
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Heart failure is one of the leading causes of morbidity and mortality worldwide. There are more than 6 million Americans living with heart failure with about 10% with advanced heart failure. Conventional heart failure therapies lead to improvement in left ventricular (LV) function in some patients, whereas in other patients, there is a progressive worsening of symptoms and cardiac function, leading to advanced chronic heart failure. These patients continue to remain symptomatic even at rest, have frequent hospitalizations due to decompensation, and have overall poor prognosis. Guideline-directed medical and device-based therapies are no longer effective in improving symptoms and cardiac function, and these patients need advanced heart failure therapies with a durable mechanical circulatory support device and heart ...