Across Two Bridges to a Heart Transplant

Abstract

Introduction Cardiac Transplantation still remains the standard care for end stage heart failure. Availability of donor hearts often prolong the waiting period and the patients may succumb to the disease. This is a major problem in developing nations like India where the donor pool is quite low compared to the recipient pool. Extra Corporeal Membrane Oxygenator (ECMO) and Ventricular Assist Devices (VAD) are effective bridges to transplant in patients who can no longer be waiting with optimal medical therapy alone . We herein describe a patient who was successfully bridged using ECMO and BiVAD (Biventricular Assist Device) to a cardiac transplant. This was the first case in our state and probably in the country wherein a BiVAD was successfully used as a bridge to transplant. Case Report A 32 year old male who worked as a software engineer developed ischemic DCM (Dilated CardioMyopathy) following a massive anterior wall myocardial infarction in 2015. Progressive cardiac failure was followed by hepatic and renal dysfunction at which point he was referred for a heart transplant. He suffered a cardiac arrest with intractable ventricular tachycardias and necessitated insertion of an ECMO. A central ECMO with aortic and bi-atrial cannulas was instituted and he was enlisted for an urgent transplant. 5 days later, this was converted into a BiVAD with centrifugal full magnetic levitated system (CentriMag, Abott).The patient was maintained on BiVAD for 14 days with the cannulas exiting through subcutaneous tunnels and sternum approximated. He was extubated and mobilized in the intensive care room. A standard biatrial orthotopic heart transplant was performed and the BiVAD was successfully weaned off. The patient had a prolonged hospital stay due to multidrug resistant bugs that grew in urine and sputum.He is now 4 years post transplant and is doing well with no evidences of rejection and maintained on standard immunosuppression. Summary ECMO and VAD are useful tools in stabilizing and optimizing patients for heart transplant when they are no longer stable on maximal medical therapy. They are effective bridges to transplant although the cost is quite formidable in developing nations wherein cost of health care is still primarily borne by the patient.