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Bi-ventricular VAD Patient Goes Home
By Margaret Lyle During the month following the birth she began to develop progressive shortness of breath. At the point when she developed dyspnea on exertion so severe that she needed to rest after a single flight of stairs, Thomas F. Whayne, MD, a cardiologist and professor of medicine at the University of Kentucky, evaluated her. A chest film showed a very large heart, and a subsequent echocardiogram revealed that her heart was extremely dilated and had evidence of markedly reduced left ventricular function (hypokinesis). She started aggressive medical therapy. Tess continued to have symptoms but was clinically stable with optimized medical management. Due to the severe degree of cardiac dysfunction and objective findings of progressive failure she was referred to the University of Kentucky Heart Transplant Program in March of 2001. At that time the surgical team felt that she was in need of heart transplantation, but she was frightened of contemplating the idea of transplantation and refused to be put on the list. By the fall of 2001, Tess had progressive symptoms of heart failure. She required several emergency room visits, and admissions to the intensive care unit. During that time her heart failure continued to progress to a point of massive dilatation (13 cm) and her heart function fell even more (ejection fraction less than 10%). In October of that year she was so sick she became dependent on continuous infusions of milrinone (intravenous heart failure medicine), both in the hospital and as an outpatient. Her overall condition was severe; she had dramatic weight loss (cardiac cachexia) and was limited to minimal activity without developing shortness of breath and chest discomfort. When Tess had reached this point of heart failure (Class IV, nearly bed ridden and dependant on medications), the transplant team evaluated her again and felt that she was appropriate for transplantation. She accepted transplantation at this point and was listed with UNOS for a new heart. Tess continued to have worsening symptoms of heart failure despite maximal medical therapy and was ill over the Christmas and New Year holidays. The severity of her heart failure troubled the members of the transplant team; they were concerned that she would not be able to live long enough to reach transplantation. Her transplant surgeon, M. Salik Jahania, MD, began to discuss the possibility of implanting a mechanical heart assist pump to “bridge” her to a transplant as she was too clinically unstable. Due to her small body habitus she was not going to be a candidate for the fully implantable Heart Mate VE Ventricular Assist Device (VAD), made by Thoratec, Inc.: the most commonly used devices in heart failure patients. A VAD is a mechanical blood pump that attaches to the patient’s heart. The blood passes into the pump through a pipe and one-way valve and is pumped out into the patient’s arteries under pressure; a VAD takes over the function of a failed ventricle. A VAD can be implantable with the tubing and pump contained within the body, or externally with tubing that passes transcutaneously to the heart. The Thoratec biventricular VAD system has an external pump and is well suited for smaller patients, and/or biventriculair support. Tess was admitted again in January 2002 for severe decompensated right and left ventricular (biventricular) heart failure and seemed to be at a point beyond the efficacy of medical management. She was initially resistant to undergoing the procedure, but as she became increasingly unstable she knew that a heart assist device was her only chance of living to transplant. In critical condition, she was brought to the operative suite on “Superbowl Sunday” for placement of a biventricular VAD. Her condition was marginal and she suffered cardiac arrest at the time that her chest was being opened. She received open cardiac massage and was emergently placed on cardiopulmonary bypass, returning blood flow to her body. Left and right-sided Thoratec VADs were placed without complication and began pumping blood to her lungs and body immediately. Her heart became a passive conduit for blood while the VADs maintained her vital signs. She ultimately recovered in the intensive care unit and moved to the CT ward where she fully recovered from her surgery. One limitation of the Thoratec VAD system is that it was not originally designed for use out of the hospital, which meant that Tess, a new mother, would have to remain in the hospital while awaiting transplantation. For a number of reasons she was expected to have a long wait for a new heart. The main function of a VAD is to return normal heart function, which in turn provides other organs normal perfusion and thus function. In Tess’s case, she returned to normal heart and organ function, and as a result, she was a “healthy” woman housed in the hospital awaiting transplantation. During this time, the Thoratec company released a portable driver unit (power unit), the TLC- II, for the Thoratec VAD system and began a FDA trial to see if this highly mobile unit would be safe for out of hospital and home use. The University of Kentucky was not originally part of that study which meant that Tess was not eligible for enrollment. Through the efforts of Dr. Jahania, the Thoratec company allowed the University of Kentucky to become a center for the FDA approved study, and with it, allowed Tess to be enrolled. Tess was discharged to home in January of 2003 to be with her child and her family. She has now been living in the community, able to move about and perform most normal activities thanks to the efforts of Dr. Jahania and the new TLC-II portable driver unit. She is followed by the transplant team and her coordinators, Julie Leigh, RN, Dorothy Lockhart, RN and BeLinda Connor, RN, Tess visits the transplant center every week for a check-in. She has done well and is living a normal life as a mother while waiting for a new heart.
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