Lead Nurse Practitioner Memorial Hermann Kingwood, Texas, United States
Background: LVADs improve survival and quality of life in advanced heart failure, but complications persist. The HeartWare HVAD (Medtronic, Minneapolis, MN) was withdrawn from the market due to neurologic and pump-failure risks. (1,2). We present a case of HVAD thrombosis causing hemolysis and shock requiring VA-ECMO and HM3 exchange.
Methods: A retrospective chart review was done to obtain all information for this case report. A 63-year-old male with ischemic cardiomyopathy, chronic HFrEF s/p HeartWare implantation (2021), CAD s/p CABG, PAD, ICD, diabetes, and recurrent GI bleeds (on warfarin INR goal 1.5–2.0) presented with tea-colored urine, abnormal LVAD hum, and mild chest discomfort. He described "sputtering" pump sounds at night. LVAD pump parameters were in normal range with a flow of 5.5 lpm at a speed of 3000rpms and power 6.3. Initial labs showed hemolysis (LDH 1307, haptoglobin < 10), elevated transaminases, rising lactic acid (6.75 mmol/L and rising creatinine. Given concerns for cardiogenic shock due to pump thrombosis he was taken for a right heart catheterization, which revealed a low cardiac index (Fick CI 1.8).
Outcome: The patient was initiated on inotropic therapy but deteriorated into worsening cardiogenic shock requiring continuous renal replacement therapy. Impella 5.5 placement with HeartWare outflow graft ligation was performed. Within 24 hours, he developed RV failure, vasoplegia, and worsening lactic acidosis requiring initiation of VA-ECMO. A few days later, the patient underwent LVAD pump exchange to Heartmate 3, bioprosthetic AVR, and RVAD implantation. Post-op course was complicated by a large hemothorax requiring re-exploration and temporary chest closure and prolonged mechanical ventilation necessitating tracheostomy. After several weeks he showed signs of RV recovery, and the RVAD was removed on POD # 28. He progressed with rehabilitation, had renal recovery and was discharged home on POD # 51.
Conclusion: This case highlights the complexity of HeartWare LVAD thrombosis. Early signs such as hemoglobinuria, high LDH, and abnormal pump sounds preceded rapid decline into cardiogenic shock. Temporary mechanical support, including Impella, ECMO and RVAD were essential for stabilization and successful exchange to HM3. Vigilance and timely device replacement remain crucial.
