Sick and going down - PowerPoint Presentation

Sick and going down “Go big or go home” KB

41 yo male with dilated nonischemic cardiomyopathy, chronic systolic CHF, VT, HTN, DM type 2 long term, AICD, prior leg DVT, sleep apnea, and morbid obesity with BMI 40-44.9. He denies alcohol, tobacco, or drug abuse. He is AB blood type. He was first seen in Transplant/MCS clinic 12/13/18 after recent discharge from an outside hospital where he had 30 pound diuresis and was discharged on Dobutamine at 5mcg/kg/min. Despite diuresis and inotropic therapy he had symptoms of DOE 20 feet, 3 pillow orthopnea, and bilateral leg edema

He was setup for right heart catheterization as a starting point in his workup on 12/18/18. Hemodynamics at RHC on Dobutamine at 5 mcg/kg/min reveal the following: RA 20, RV 72/23, PA 78/53 with mean 53, PAW mean 35, Fick CO/CI 3.58/1.41, PA O2 33.8%, TPG 18 , PVR 5.03. HR 75 , CVP/PAW ration 0.57, RVSWI 490, and PAPI 2.0

Echo 12/18/18 revealed severe LV enlargement (7.08 cm)/mild LVH/severe global LV dysfunction with EF10-15%, restrictive LV filling pattern, moderate biatrial enlargement, mild Rv enlargement/normal RV thickness/mild RV dysfunction, mild to moderate MR, mild TR, mild to moderate pulmonary HTN (underestimate of measured PASP) Lab reveals Na 140, BUN/Cr 24/1.47, GFR 52.7, pro BNP 3359, PT INR 1.3, and total bilirubin 4.3

CXR reveals mild pulmonary edema (PAW 35), no pleural effusions, and stable cardiomegaly EKG reveals sinus tachycardia, right superior axis deviation, and borderline nonspecific ST change laterally. QRS duration 110 msec Exam reveals morbid obesity, JVP to angle of jaw, clear lung fields, S3 gallop, 2/6 MR mumur, and bilateral leg edema

Question #1 Based on this history and all collected data, what AHF therapy is he eligible for at this moment? A.Transplant B. LVAD C. Both LVAD and transplant D. Neither LVAD or transplant

Answer #2 D. Neither LVAD or transplant

Question #2 What lab result scares you the most? A. Na 140 B. GFR 52.9 C. INR 1.3 D. total bilirubin 4.3 E. BNP 3359

Answer #2 D. total bilirubin 4.3

Question #3 The patient is an outpatient in the cath lab with the listed hemodynamics. What do you do now? A. Send home with increased diuretics B. Send home with increased diuretics and increase Dobutamine dose C. Admit to the hospital

Answer #3 C. Admit to the hospital

He is admitted to the hospital. His Dobutamine is increased to 10 mcg/kg/min with his low SVO2/low CI. He is started on IV Lasix drip after bolus with CVP 20 and PAW 35. On 12/22/18, he had VT requiring AICD shock with normal electrolytes. Milrinone was added to allow decrease of Dobutamine and IV amiodarone started. On 12/24/18, his CVP is now down to 12 mm Hg after 4 liter/10 pound diuresis. His CI is good at 2.6 on Milrinone 0.75 mcg/kg/min and DB at 3 mcg/kg/min. With the diuresis, he has first attack of left ankle gout treated with steroids and colchicine.

On 12/27/18, he states he “feels great” on the same two inotropes. He was made aware that he will not able to be discharged home safely until transplant or LVAD. On 12/29/18, updated hemodynamics in the ICU reveals CVP 16, PA 73/36 mean 46, PAW 32, TPG 14, PVR 2.03, CO/CI 6.9/2.9. His lab update reveals Cr 1.42, GFR 54.9, total bilirubin down to 2.0, and Na of 129. BMI down to 35 after diuresis.

Question #4 Does he meet criteria for transplant and if so what status in the new 7 tier system adopted 10/18/18 ? He has a PA line, 2 inotropes, and meets new UNOS criteria for cardiogenic shock with CI 2.1, BP 82/49 and PAW 19 all within one 24 hour period. A. still doesn’t qualify for transplant B. qualifies and list as status 1 C. qualifies and list as status 3 D. qualifies and list as status 6

Answer #4 C. qualifies and list as status 3

Question #5 What is the best blood type for a potential heart transplant recipient even with the new 7 tier system? A. AB B. B C. A D. O

Answer #5 A. AB blood type

Question #6 What is the blood type of a potential recipient with the most competition for a suitable donor given the same UNOS listing status within the new 7 tier system? A. AB B. B C. A D. O

Answer #6 D. O blood type

He is listed status 3 on the National waitlist on 12/28/18. He gets a few donor offers being AB blood type at status 3. However, none of the offers are great and patient is stable with no patients on the national waitlist for AB hearts at status 1 or 2.

Question #7 What factor(s) is/are the most important for donor selection in terms of recipient outcome? A. Donor age B. Donor history of drug abuse C. Total ischemic time (distance from donor to recipient) D. A and C E. B and C F. All the above

Answer #7 D. A and C (donor age and total ischemic time)

On 1/6/19, he is stable at rest with SVO2 57% at rest on Milrinone at 0.75 mcg/kg/min but decreases to 45% just getting up to a chair On 1/8/19, he is more unstable with CVP 18, CI 1.9, PAO2 30 , PAW 35, SBP 89, and PA mean 45. He also has afib/aflutter while on amiodarone for prior VT and amiodarone dose increased.

Question #8 With the patient stable on the 2 inotropes (Milrinone 0.75 and DB 3 ) for 15 days and now failing fairly quickly, what do you do now? A. Tandem Heart in LA/FA configuration B. femoral IABP (easier cannulation but decreased mobility) C. axillary IABP (trip to the OR but able to ambulate) D. increase Dobutamine with recent afib and initial VT E. Protek Duo LV apical cannulation with pump

Answer #8 C. axillary IABP (trip to OR but allows ambulation)

On 1/9/19, left axillary IABP placed. CVP up to 20 and patient placed on IV Lasix infusion with vascath placement for ultrafiltration. Cr now up to 1.79 mg/dl On 1/10/19, the patient still not doing well and patient taken for placement of 31F Protek duo catheter via the LV apex with Centrimag as the pump (higher BMI) with membrane oxygenator and 6 liter left sided support. Patient upgraded to status 2.

On 1/11/19, he is still on is still intubated and an aspiration event probably at the time of his axillary iabp placement is suspected. His PA pressures are 55/24 mean 34 , CO/CI 4.8/2.0, and SVO2 48% despite 6 liter ecmo circuit flow to left side. He is on levophed and both Dobutamine/Epinephrine for now RV support. His Cr is now 2.59 down from a peak of 2.91 mg/dl.

On same day 1/11/19, his ECHO reveals the following: severe LV enlargement (6.97 cm)/severe global LV dysfunction with EF less than 20%, moderate LA enlargement, mild RV enlargement with moderate RV hypokinesis , severe RA enlargement, moderate AR (increased with Protek duo catheter across the aortic valve), trace MR, and mild TR On 1/13/19, his LFT’s rise with AST 145, ALT 77, alk phos 125, and total bilirubin up to 5.8. his CVP is now 17. He is still on significant support despite t h e Protek Duo LV support with patient on epinephrine, Levophed , DB, Milrinone , and the axillary IABP. Over the last 3 days, the degree of hemolysis has increased with LDH levels increasing 397,547, and 967.

On 1/14/19, his LDH is now 1385. The Centrimag flows are 6.6 liters to support his BMI and increasing needs with his aspiration pneumonia. SVO2 despite this high flow is marginal at 54%. His CO /CI are 4.9/2.0. His PA pressures are 55/26 with mean of 36. Despite the same continued support and 8 liter net negative balance the prior day, his total bilirubin rises to 6.0 On 1/15/19, his LDH is up to 1609, CVP 17, PA 60/30 mean 40, CO/CI 4.4/1.9, and SVO2 54%

Question #9 He is not turning around due to RV failure. Also, he is having significant hemolysis with the required high flows required to support him with the 31F Protek duo catheter. What is your next step? A. more inotropes for RV failure B. RVAD centrimag C. change to bilateral centrimags D. Total artificial heart placement if possible

Answer #9 C. change to bilateral centrimags (TAH not available at this center)

On 1/15/19, due to the RV failure and the hemolysis with the current set up with the high flows needed to meet increased needs and BMI, he goes to to the OR for the 3rd time with removal of the apical Protek duo catheter/axillary and placement of bilateral centrimag devices with usual configuration of LV apical drainage with outflow to aorta and RV drainage with RV cannula through RA and down through tricuspid valve and outflow to the PA. OR complicated by major SIRS response with vasoplegia with use of steroids and IV methylene blue

RVAD flows 4.9 at 2800 rpm and LVAD flow 4.63 at 3550 rpm. very unusual reversal with RVAD flows typically slightly less than LVAD flows… with TEE guidance found to require higher RVAD flows and CVP above 10 to have decent flows On 1/16/19 (one day postop), LDH dropped to 915 even with bilateral pumps (LDH 1000 or less acceptable)

On 1/19/19 (4 days after his 3rd trip to the OR), he is off all inotropes and pressor (was on 4). For his pulmonary hypertension, he is still on NO at 80 ppm via NC (extubated) and IV Revatio at 60 mg over 24 hours. Based on continued RV dilatation on echo, his RVAD speed increased to decompress right side. Echo revealed mild LV enlargement/severe LV dysfunction with EF less than 20%, mild LA enlargement, severe RA enlargement, severe RV enlergement with sever Rv hyokinesis , mild to moderate MR, and moderate TR .. LVAD 3600/5.1..RVAD 2900/5.1

His peak total bilirubin was 6.9 with direct bilirubin 5.4 (indirect 1.5) on 1/19/19 and by 2/2/19 his total bilirubin was 3.1 with direct bilirubin 2.8 (indirect 0.3). By 2/2/19, his Hct was 23.9 (trying not to transfuse) and still on CRRT since implantation of bilateral centrimags but able to come off CRRT to allow ambulation. Now able to walk hall half way around ICU unit

Question #10 When do you reactivate him from status 1a which he can remain at indefinitely due to RV mechanical support? A. reactivate as status 1 now with on going CRRT and elevated bilirubin B. reactivate as status 1 when bilirubin less than 3 (no jaundice) even with ongoing CRRT C. reactivate him when bilirubin less than 3 and renal recovery has occurred.

Answer #10 B. reactivate with total bilirubin less than 3 (no jaundice) and with ongoing CRRT Unclear what right answer is to this one. We are waiting to get him stronger and clear infiltrates on CT of chest from his aspiration pneumonia. We believe his renal function will recover in time. We are balancing risk of ongoing ICU stay versus transplanting with renal dysfunction .

THE END OF CASE