Heart* to Heart*: Thrombosed HeartWare LVAD Exchanged to a Heartmate 3 LVAD

Introduction Left ventricular assist devices (LVADs) have undergone technological advances over the past several years, however, device thrombosis remains a feared complication. We present a case of a HeartWare HVAD presenting with pump thrombosis which failed medical therapy and was exchanged for an Abbott HeartMate 3 pump. Case Report The patient is a 38-year-old male with end stage-systolic heart failure due to a HIV associated cardiomyopathy who underwent HVAD implantation six years prior to presentation. The patient was in his usual state of health when he presented to the hospital due to a "high watt" alarm. He was asymptomatic. The patient, who was maintained on aspirin and warfarin, had a presenting INR which was subtherapeutic (1.2). Interrogation of the device logs showed an abrupt increase in power up to 9W with flows >10 L/min (baseline ∼4.5W and ∼5.5 L/min) (Figure). Computed tomography (CT) angiogram did not reveal an outflow graft thrombosis but did note pulmonary edema. The patient was diagnosed with pump thrombosis and was initially treated with two doses of alteplase 20 mg (Figure arrows). The power and flow normalized. Multiple lactate dehydrogenase (LDH) specimens were hemolyzed, but the LDH 3 days after admission ultimately was 3,550 U/L (baseline 268 U/L). Two days later, power spikes recurred. The patient was given one dose of alteplase 50 mg without success. The patient underwent emergent exchange to a HeartMate 3 LVAD via a re-do sternotomy. Surgery was notable for the epicardial ring of the HVAD being firmly incorporated at the left ventricular apex. To minimize trauma, the epicardial ring of the HeartMate 3 was sutured directly onto the epicardial ring of the HVAD. The Heartmate 3 was then inserted through both epicardial rings while the outflow graft was anastomosed to the remnant outflow graft of the HVAD. The patient did well post-operatively and was discharged on post-operative day number 15. Summary A thrombosed HVAD can be successfully managed with exchange to a HeartMate 3 LVAD.