ABC | Volume 111, Nº1, July 2018

Case Report Left Ventricular Assist Device as a Bridge to Candidacy in End-stage Chagas Cardiomyopathy Fernando Antibas Atik, Claudio Ribeiro Cunha, Renato Bueno Chaves, Marcelo Botelho Ulhoa, Vitor Salvatore Barzilai Instituto de Cardiologia do Distrito Federal, Brasília, DF – Brazil Mailing Address: Fernando Antibas Atik • SQNW, 110, BLOCO J, Apto. 308. Postal Code: 70686550, Noroeste, Brasília, DF – Brazil E-mail: atik@cardiol.br Manuscript received August 16, 2017; revised manuscript September 18, 2017; accepted September 25, 2017. Keywords Chagas Cardiomyopathy; Heart Failure; Shock, Cardiogenic; Hypertension, Pulmonary; Extracorporeal Circulation. DOI: 10.5935/abc.20180095 Introduction Chronic Chagas cardiomyopathy manifests late after Trypanosoma cruzi infection, and it is still one of the major causes of end-stage heart failure in Latin America. 1 Published experiences 2,3 with heart transplantation for chronic Chagas disease have shown the feasibility and efficacy of this therapy, being the disease reactivation not a major concern when appropriately diagnosed and timely treated. 4 Nevertheless, the need for some sort of mechanical circulatory support on the waiting list has progressively increased, according to the International Society for Heart and Lung Transplantation Registry annual report. 5 Since the experience with mechanical circulatory support in Latin America is very limited, and biventricular systolic failure is common in Chagas cardiomyopathy, many unanswered questions regarding modalities of support need to be elucidated. This case report describes the successful implant of an axial flow left ventricular assist device in a patient with end-stage heart failure with severe biventricular failure secondary to Chagas cardiomyopathy. Case Report A 26-year-old male, with a history of long-standing heart failure had multiple hospital admissions in the past year despite optimal medical management. The diagnosis of end-stage heart failure due to Chagas cardiomyopathy was confirmed by serology a while ago, and an implantable cardioverter defibrillator was used for sudden death secondary prevention. Echocardiography revealed a severely dilated left ventricle (end-diastolic diameter of 72 millimeters), with severely depressed function (ejection fraction of 18%) and 4+ mitral regurgitation. The right ventricle also exhibit severe dysfunction with 3+ tricuspid regurgitation, tricuspid annular plane systolic excursion of 15, and right ventricular systolic pressure of 65 mmHg. The patient has been followed up in a different city of ours by another cardiology team. At this point, he has never been considered for heart transplantation. Nonetheless, the patient was admitted in the emergency room with cardiogenic shock, in Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) level 2. He was initially managed with the use of two inotropes, intra-aortic balloon pump and hemodialysis. No temporary or durable mechanical assist devices were available at this hospital. A right heart catheterization revealed low cardiac output (cardiac index of 0.9 L/min/m 2 , with systolic pulmonary pressure of 70 mmHg, transpulmonary gradient of 16 mmHg and pulmonary vascular resistance of 6 Wood units. Filling pressures were elevated (central venous pressure and pulmonary wedge pressure of 30 mmHg). The patient was transferred to our hospital for heart transplantation assessment. At admission, he had sudden hemodynamic instability that deteriorated into cardiac arrest. Cardiopulmonary resuscitation measures were effective, but circulation was maintained with escalating doses of vasopressors. A percutaneous venous arterial extracorporeal life support (ECLS) (Maquet Getinge TM , Germany) through the femoral vessels was inserted as a bridge to decision strategy. Hemodynamics stabilized, vasopressors were discontinued, tissue perfusion indices normalized, and the patient neurologic status was intact. He was extubated on the next day, renal function normalized, an aggressive diuresis allowed a twelve-liter negative fluid balance in the following five days (Figure 1). Eighteen days after ECLS initiation, the patient was submitted to an axial flow left ventricular assist device (HeartMate II, Abbott Laboratories TM , Chicago, IL) implantation with ECMO explant under median sternotomy with cardiopulmonary bypass. Postoperatively (Figure 2), the patient had mediastinal bleeding requiring surgical revision; coagulopathy and pericarditis. A transient right ventricular dysfunction required a five-day administration of intravenous inotropic support, aggressive diuresis and oral pulmonary vasodilators. He was eventually discharged home on postoperative day 35 in fair condition, requiring rehabilitation due to malnutrition and muscular weakness. Sixteen months later, he is in functional class I with unremarkable recovery except for a single episode of hemolysis that was treated with intravenous heparin. Pump has functioned well with no evidence of failure or thrombosis. Late right heart failure was not an issue, and his exercise performance is excellent. Echocardiography revealed mild tricuspid regurgitation and right ventricular systolic pressure of 30 mmHg. At this point, the patient does not manifest interest in being transplanted. 112