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Hemodynamically Stable Asymptomatic Sustained Ventricular Fibrillation in a Patient with Left Ventricular Assist Device
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A3433 - Hemodynamically Stable Asymptomatic Sustained Ventricular Fibrillation in a Patient with Left Ventricular Assist Device
Author Block: P. Jha1, S. Mahboob2, P. Macauley3, J. Samaroo-Campbell4; 1Internal medicine, Maimonides medical center, Brooklyn, NY, United States, 2public health, wayne state university, detroit, MI, United States, 3Internal medicine, Maimonides Medical Center, Brooklyn, NY, United States, 4Internal medicine, Maimonides Medical Center, NEW YORK, NY, United States.
Hemodynamically Stable and Asymptomatic Sustained Ventricular Fibrillation in a Patient with Left Ventricular Assist Device
Introduction
Ventricular fibrillation (VF) a fatal arrhythmia which inevitably results in death is not uncommon in advanced heart failure. Continuous-flow Left ventricular assist devices (LVADs) are used to maintain systemic and pulmonary circulation and hemodynamic stability in end stage heart failure. In addition to symptomatic improvement, survival and quality of life is improved. Interestingly, rhythm disturbances are also one of the most common complications of these devices. Although not their primary use, LVADs are instrumental in preventing death as a result of cardiac arrhythmias. We present a case of a young man with continue-flow non-pulsatile LVAD who presented with hemodynamically stable asymptomatic sustained ventricular fibrillation.
Case presentation
A 35-year old male from Panama presented to the LVAD clinic for routine checkup. The LVAD had been placed 6 months earlier as a bridge to heart transplant for non-ischemic cardiomyopathy. During one of his follow up appointments, a routine electrocardiogram showed ventricular fibrillation. There were no signs of hemodynamic instability and he was completely asymptomatic. He was immediately transferred to the cardiothoracic surgery unit were his electrolytes were aggressively repleted and an infusion of amiodarone was initiated. Crystalloid infusions were given for low pulse index followed by adequate sedation and successful defibrillation which resulted in successful restoration of sinus rhythm. The next day, an automated implantable cardioverter-defibrillator (AICD) was placed and he was discharged home.
Conclusion
Ventricular arrhythmias are quite common in LVAD patients, and monomorphic ventricular tachycardia is the most often encountered, although a few cases of VF have also been reported. There are two mechanisms proposed; (1) over suction by the pump can cause collapse of the ventricular chamber resulting in direct contact of the outflow tract and the ventricular wall which triggers arrhythmias; (2) rapid electrolyte shifts are often seen in these patients which also predispose to malignant rhythms. The mortality rate can be as high as 54% and other than sudden death, such sustained rhythms lead to progressive right heart failure, orthostasis and thrombus formation. The use of AICD to prevent sudden cardiac death in these patients has not shown much efficacy. It is therefore important to aggressively monitor and address this should it be observed in any LVAD patient.
Reference:
Kadado AJ et al. 2017. Arrhythmias after left ventricular assist device implantation: Incidence and management. Trends Cardiovasc Med. S1050-1738(17)30105-6.
Author Block: P. Jha1, S. Mahboob2, P. Macauley3, J. Samaroo-Campbell4; 1Internal medicine, Maimonides medical center, Brooklyn, NY, United States, 2public health, wayne state university, detroit, MI, United States, 3Internal medicine, Maimonides Medical Center, Brooklyn, NY, United States, 4Internal medicine, Maimonides Medical Center, NEW YORK, NY, United States.
Hemodynamically Stable and Asymptomatic Sustained Ventricular Fibrillation in a Patient with Left Ventricular Assist Device
Introduction
Ventricular fibrillation (VF) a fatal arrhythmia which inevitably results in death is not uncommon in advanced heart failure. Continuous-flow Left ventricular assist devices (LVADs) are used to maintain systemic and pulmonary circulation and hemodynamic stability in end stage heart failure. In addition to symptomatic improvement, survival and quality of life is improved. Interestingly, rhythm disturbances are also one of the most common complications of these devices. Although not their primary use, LVADs are instrumental in preventing death as a result of cardiac arrhythmias. We present a case of a young man with continue-flow non-pulsatile LVAD who presented with hemodynamically stable asymptomatic sustained ventricular fibrillation.
Case presentation
A 35-year old male from Panama presented to the LVAD clinic for routine checkup. The LVAD had been placed 6 months earlier as a bridge to heart transplant for non-ischemic cardiomyopathy. During one of his follow up appointments, a routine electrocardiogram showed ventricular fibrillation. There were no signs of hemodynamic instability and he was completely asymptomatic. He was immediately transferred to the cardiothoracic surgery unit were his electrolytes were aggressively repleted and an infusion of amiodarone was initiated. Crystalloid infusions were given for low pulse index followed by adequate sedation and successful defibrillation which resulted in successful restoration of sinus rhythm. The next day, an automated implantable cardioverter-defibrillator (AICD) was placed and he was discharged home.
Conclusion
Ventricular arrhythmias are quite common in LVAD patients, and monomorphic ventricular tachycardia is the most often encountered, although a few cases of VF have also been reported. There are two mechanisms proposed; (1) over suction by the pump can cause collapse of the ventricular chamber resulting in direct contact of the outflow tract and the ventricular wall which triggers arrhythmias; (2) rapid electrolyte shifts are often seen in these patients which also predispose to malignant rhythms. The mortality rate can be as high as 54% and other than sudden death, such sustained rhythms lead to progressive right heart failure, orthostasis and thrombus formation. The use of AICD to prevent sudden cardiac death in these patients has not shown much efficacy. It is therefore important to aggressively monitor and address this should it be observed in any LVAD patient.
Reference:
Kadado AJ et al. 2017. Arrhythmias after left ventricular assist device implantation: Incidence and management. Trends Cardiovasc Med. S1050-1738(17)30105-6.
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