Double Trouble during LVAD Implantation (Bardoczi, Rosenthal-Garcia, Lumsden, Garami, Akay)

Right heart failure (RHF) frequently occurs after durable left ventricular assist device (dLVAD) placement. Some factors contributing to post-dLVAD RHF remain unknown but may involve the thousands of air microbubbles that frequently appear after pump initiation and are detectable using transcranial Doppler (TCD) and transesophageal echocardiography (TEE). This case report demonstrates the simultaneous use of TEE and TCD to detect microbubbles in the ascending aorta and microembolic signals in the brain during left ventricular assist device (LVAD) placement. A 37-year-old male underwent implantation of HeartMate3 dLVAD to treat heart failure. After pump initiation, microbubbles were observed via TEE and TCD. The final intracerebral embolus count via TCD was 1202 in the right middle cerebral artery and 2027 in the left. The patient subsequently progressed into RHF, which was managed with conservative measures. In summary, dLVAD initiation caused massive amounts of embolizing air microbubbles with the potential to negatively impact both cerebral and myocardial function. The anatomic position of the right coronary artery (RCA) ostium could cause embolizing air from the ascending aorta to enter the RCA, causing ischemic insult to the right ventricle and increasing the chance of RHF. Simultaneous monitoring with TEE and TCD can help to quantify embolizing air bubbles during dLVAD implantation and help establish an association between air embolization and RHF.

Objectives:

1. Teach the audience about the intraoperative use of TCD
2. Build the hypothesis of air embolization playing a role in post-LVAD implantation right heart failure
3. Give a practical way to utilize air embolization, as detected by TCD, as a tool to predict right heart failure


** This medical education program may contain graphic content. **
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