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Curso de Atualização em Medicina Cardiovascular 2019
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05. Atrial Fibrillation
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07. Syncope and Bradycardia
08. Ventricular Arrhythmias and Sudden Cardiac Death (SCD)
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Heart Mate3 as destination therapy in Dilated Cardiomyopathy: Regaining functional autonomy on the shoulders of the Right Ventricle
Session:
Sessão de Casos Clínicos - II
Speaker:
Afonso Félix Oliveira
Congress:
CPC 2019
Topic:
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Theme:
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Session Type:
Sessão de Casos Clínicos
FP Number:
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Authors:
Afonso Félix De Oliveira; António Tralhão; Carlos Aguiar; Miguel Abecasis; Christopher Strong; Márcio Madeira; Sara Ranchordás; Miguel Mendes; José Pedro Neves
Abstract
<p><strong>Introduction: </strong>The HeartMate3 device has recently become available in Portugal, having the potential to improve quality of life for end-stage heart failure (HF) patients. It is important to discuss the clinical conundrums of managing such patients in order to develop successful programs in our country.</p> <p><strong>Clinical case:</strong> We present the case of a 73 years old male patient admitted in our acute care unit in NYHA IV, with wet/cold profile under inotropic support. The patient had the diagnosis of HFrEF (LVEF~10%) and non-revascularizable coronary artery disease. He was admitted after 4 days from last HF discharge, with acute HF and no obvious cause for decompensation. Inotropes were started and the patient remained dependent on Dobutamine – INTERMACS 3. The evaluation for ambulatory LVAD analyzed oncological status, respiratory function, and excluded end-organ dysfunction – Creatinine 1.1mg/dL with normal liver tests. Echocardiography showed mild mitral, aortic and tricuspid regurgitation with RV function parameters of EDV-3D 96mL/m2, ESV-3D 78mL/m2, EF 19%, FAC 22%, TAPSE 14mm and Sm.RV 9cm/s. Clinical assessment of RV function was of paramount importance to decide on patient eligibility and evaluate the need for bridge right ventricle assist device in the post-OP. Right heart catheterization under dobutamine showed CVP 8mmHg, PCWP 24mmHg, mPAP 28mmHg, CO 3 L/min and PVR of 1.33 Woods. Despite RV dysfunction on echo, low CVP and PVR, normal liver tests and clinical signs of predominantly left HF deemed the patient appropriate for HM3 with conditional RVAD in the post-OP. In the OR, the continuous flow magnetically suspended axial pump was placed in the LV apex with an outflow cannula in the ascending aorta without complications. The patient exited the OR without RVAD and under Nitric Oxide and inotropic support. In the early post-OP, pharmacological and ventilatory support were successfully stopped. Pump rotation adjustments were performed echo-guided, with the goal of increasing cardiac output and reducing systemic and pulmonary congestion. “Suction events” happened when the LV was adequately unloaded but the RV remained dysfunctional. As the recovery progressed, and RV function gradually improved due to reduced afterload, congestion decreased and pump function stabilized. The patient has regained his functional autonomy and is currently enrolled in our outpatient rehabilitation program. At 6 months follow-up, pump parameters are 5300rpm for a pump flow of 4.2L/min. Until today, the patient has been free from bleeding, ischemic or device infection events without further hospital readmissions.</p> <p><strong>Conclusion:</strong> This case illustrates the impact of ambulatory LVAD in the quality of life of patients with end-stage HFrEF. Critical Peri-OP evaluation and management are essential for the success of these programs in our country.</p>
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