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Acute Decompens a tion “slip sliding away” BF

Acute Decompens a tion “slip sliding away” BF. 38 yo male diagnosed with systolic heart failure/ dilated nonischemic cardiomyopathy in March 2018

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Acute Decompens a tion “slip sliding away” BF

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  1. Acute Decompensation “slip sliding away” BF

  2. 38 yo male diagnosed with systolic heart failure/ dilated nonischemic cardiomyopathy in March 2018 • He was admitted to our hospital 8/2/18 after transfer from a local hospital with high risk features of persistent inotrope requirement, increasing runs of non sustained VT, inability to tolerate GDMT, and persistent GI complaints of nausea and decreased appetite • He has had a decreased appetite for 6 months and has lost 60 pounds in total

  3. Past medical and social history includes a GB removal in June 2018 and 0.5 ppd smoking from age 21 till stopped in march 2018/drinking daily since age 21 with periods of time up to a pint of Vodka daily • He worked full time up until admission as a truck driving instructor • No AICD/AB blood type/abd USat outside hospital with ascites/periportal echogenicity but no focal hepatic abnormality

  4. Exam reveals muscular appearance, JVP to angle of jaw, clear lungs, S3 gallop, 2/6 MR murmur, 2/6 TR murmur and no peripheral edema • Lab reveals Na 135, BUN/Cr 8/0.9, GFR over 60,TSH 6.97, total bili3.0, albumin 3.0 and normal transminases • Hemodynamics after Swan placed while on DB at 5 mcg/kg/min.. CVP14 and SVO2 41% with increase to 55% with DB increased to 10 mcg/kg/min..BP 101/65 with a mean of 78

  5. CXR reveals heart size/contour normal with clear lung fields • Echo reveals severe LV enlargement (6.72 cm)/no LVH/severe global LV dysfunction EF 10%, restrictive LV diastolic filling, moderate biatrial enlargement, moderate RV enlargement/normal RV thickness/moderate RV hyperkinesis, moderate MR, moderate TR, and estimated PASP of 58 mm Hg

  6. Question #1 • What high risk features does he have? • A. S3 gallop on exam • B. ascites • C. inability fo tolerant GDMT HF meds • D. right sided HF and low output symptoms with loss of appetite and nausea • E. Total bilirubin of 3 mg/dl • F. All the above

  7. Answer #1 • E. All the above

  8. Question #2 • What bothers you most at this point specifically for transplant? • A. 60 pound weightloss and its cause • B. Etoh/tobacco abuse • C. LVEF 10% • D. Moderate RV enlargement with moderate RV hypokinesis • E. Ascites with total bilirubin of 3.0

  9. Answer #2 • A. 60 pound weight loss and its cause

  10. Question #3 • What worries you the most for implantation of a durable LVAD? • A. 60 pound weight loss and its cause • B. Etoh/tobacco abuse • C. LVEF 10% • D. Moderate RV enlargement with moderate RV hypokinesis • E. Ascites and total bilirubin of 3.0

  11. Answer #3 • D. Moderate RV enlargement and moderate RV hypokinesis

  12. Question #4 • On the day after admission while on Dobutamine of 10 mcg/kg/min, his SVO2 drops to 41% and no workup for AHF therapies has been started. His SBP is 100. What do yo do next? • A. increase inotropes • B. Increase vasodilators • C. place and IABP • D. place Impella 5.0 via shoulder surgically • E. place Tandem heart via LA/FA configuration

  13. Answer #4 • A. increase inotropes

  14. On 8/3/18 (day after admission), we now escalated to two inotropes with Milrinone added at 0.5 mcg/kg/min and Dobutamine at 10 mcg/kg/min. All consultantsget involved ( team sport). • On 8/4/18, progressive cardiogenic shock with SVO2 drop to 30% on the 2 inotropes with heart rate 125 bpm. Femoral IABP added with rate turned down to 1:2 due to heart rate. He is autoanticaogulated with INR 1.83 now. • On 8/5/18, with the above support, CI 2.0, SVO2 64%, CVP 11, and PA 46/20 with mean 27

  15. Question #5 • What is your next step if further decompensation occurs? • A. Impella 5.0 via shoulder surgically • B. Tandem heart device with LA/FA configuration • C. Protek Duo catheter via LV apex and across the aortic valve with pump +/- membrane oxygenator • D. List for transplant as Status 1A (now would be status 2)

  16. Question #5 • C. Protek Duo catheter via LV apex with pump +/- membrane oxygenator

  17. On 8/6/18, 2 main issues to go forward are not clear..1. Does he have cirrhosis from alcohol, cardiac cirrhosis from chronic congestion, or combination? What is the degree and type of fibrosis? increasing fibrosis increases the risk of transplant …remember cardiac related fibrosis “inside out” and noncardiac related fibrosis “outside in” 2. What is the etiology of his weight loss and why does he have continued low appetite despite current adequate cardiac support?

  18. On 8/6/18 (4 days after admission), he is on Milrinone 0.5 mcg/kg/min, IABP now 1:1, and DB increased to 15 mcg/kg/min. Levophed added to keep SBP 90 mm Hg. Updated hemodynamics are CVP 14, PA 46/17 mean 29, PAW 25, TPG 4 , PVR1.08, HR 90, CO/CI 3.7/1.9,CVP/PAW ratio 0.56, RVSWI 316, PAPI 2.04

  19. Question #6 • Based on this updated hemodynamic data on current support, will the patient do well with a durable LVAD with no RV mechanical support ? • A. Yes • B. No

  20. Answer #6 • B. No

  21. On 8/8/18, EGD shows gastritis with no varices. The liver biopsy from the 8/7 transjugular biopsy result comes back with findings of hepatic congestion and NO evidence of cirrhosis or fibrosis. Total bilirubin still 3.7 mg/dl but GAME ON!

  22. Question #7 • So , what is your next step with the patient of 2 inotropes, 1 pressor, and femoral iabp1:1 with inability to ambulate? • A. durable LVAD implant • B. list for transplant status 1a (now status 2) and wait • C. list for transplant and place short term support like Impella or LV Centrimag • D. list for transplant with Impella 5.0 via shoulder and remove femoral IABP to allow ambulation • E. list for transplant and place central cannulation bilateral Centrimags with sternotomy and unlimited status 1a time (currently status 1) • F. too sick to list now • G. Protek due LV apical cannulation with outflow beyond aortic valve with membrane oxygenator

  23. Answer #7 • G. Protek Duo LV apical cannulation with outflow beyond aortic valve with membrane oxygenator

  24. With the good news about liver biopsy, he is listed for transplant and a Protek Duo with LV apex cannulation is placed on 8/10/18 with outflow beyond aortic valve with Tandem heart pump at max rpm of 7000 rpm with 4.1 liter flow. BMI 25.3 with height 5’11’’ and weight 181 lbs. • On 8/12/18, patient extubated and up in chair with IABP out • On 8/14/18, he is walking in the hall on Milrinone 0.375 mcg/kg/min and DB 2.5 mcg/kg/min now for RV support.. LV mechanically supported and continued need for inotropes due to RV

  25. On 8/15/18, 2 problems arise.. 1. SVO2 drops to 42% with Tandem heart pump at max speed of 7000 rpm and flow 4.1 liters per min 2. CVP up to 20 with decreased urine output. • Hemodynamics show CVP 20, PA 47/22 mean 34. PAW not possible, and SVO2 42% • Lasix bolus and infusion started, stat echo obtained, one unit price given for low hct less than 23 although tried to limit transfusion to decrease antibody formation. SVO2 is also depending on carry capacity. No significant hemolysis with current mechanical support despite high rpm with LDH 370

  26. The patient stabilized with these interventions • On 8/16/18, IV Revatio was added to help with pulmonary hyertension and RV rescue • On 8/18/18, vascular tone increased requiring IV Cardene for BP control ( goal MAP 70-75) with Tandem Heart flow down to 3.5 liters per minute. LV mechanical support sensitive to afterload. • On 8/21/18, his ELISA test for heparin associated platelet antibody is positive with SRA drawn but pending. His Heparin changed to GFR based Angiomax (Bivalrudin) protocol

  27. Question #8 • What is true about a positive Heparin associated platelet antibody? • A. the antibody present for 90 days • B. no amnestic response • C. risk scores such as the 4T’s and HEP score help assess risk and have available phone apps • D. Heparin should be stopped with the positive ELISA test till SRA test back • E. Low molecular with heparins have 1/10th the risk of HIT as unfractioned heparin • F. All the above

  28. Answer #8 • F. All the above

  29. On 8/23/18, he has good urine output of Lasix drip and CVP down to 12 mm Hg. He is well supported with CO /CI 5.2/2.6 • On 8/27/18, patient sluggish and Tandem heart pump increased to 6800 rpm with flow increased from 3.5 liters to 3.8 liters with membrane oxygenator FiO2 0.4 and sweep of 0.5. LDH higher but still acceptable at 529. Acceptable donor found 8/28/18. • On 8/29/18, underwent transplant with transient intraoperative RV dysfunction and high degree AV block with both resolve with techniques to remove likely air down the RCA

  30. On 8/31/18, went back to the OR to washout right hemothorax • On 9/1/18, he has signs of RV dysfunction on echo with mild RV enlargement/moderate RV hypokinesis. TAPSE 0.5 cm (abnormal less than 1.7 cm) and RV S’ 4.21 cm/sec (abnormal less than 9.5 cm/sec.. both superior /more quantitive assessment of the RV longitudinal function

  31. On 9/2/18, with pulmonary vasodilators of NO/oral revatio, time passage, and Milrinone at 0.5 mcg/kg/min, his RV function by echo improves • On 9/4/18, his first EMBX done with RA 8 AND RV 38/10.. Grade 1R ACR (old grade 1a) and grade 0 AMR • Over the next 7 days, his milrinone and NO weaned slowly off. His second EMBx done 9/11/18 done with exactly same findings hemodyamically and pathology wise • On 9/12/18 (14 days post transplant and 41 days post admission), he is discharged home with a bilirubin of 1.3 mg/dl

  32. THE END OF CASE

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