A 56-year-old caucasian male with dilated cardiomyopathy was previously treated with an implantable cardiac defibrillator (ICD) as secondary prevention therapy (2002) and with a combined system of cardiac resynchronization therapy (CRT) and ICD—CRT/ICD therapy (2009) with several infectious complications, which led to explantation of the system and reimplantation of the CRT/ICD (surgically implanted epicardial electrode; 2010).
The patient was admitted to our institution (12/2010) from a referral hospital in cardiogenic shock with arrhythmic storm triggered with incessant monomorphic ventricular arrhythmia. Radiofrequency (RF) ablation was unsuccessful, so urgent implantation of an LVAD—HeartMate II (Thoratec Corporation, Pleasanton, CA, USA) was indicated. The procedure was performed in a standard fashion under transesophageal echocardiogram (TEE) guidance together with De Vega tricuspid valve annuloplasty and cryodestruction of arrhythmogenic substrate.
During the entire postoperative period, repeated life-threatening septic complications were observed. The patient was treated gradually with antibiotics to 02/2011 (meropenem, linezolid, fluconazol, anidulafunginum, cefepime, ampiciline, micafungin, piperacilline/tazobactam). Computed tomography (CT) scans showed signs of pulmonary interstitial pneumonia in both lungs from 12/2010 to 2/2011. During this period, it was necessary to intubate the patient several times because of respiratory insufficiency. Clinical signs of infection disappeared after prolonged treatment with broad-spectrum antibiotics. In early 2/2011 CT scans, bronchoscopy with lavage, and blood cultures were negative.
The patient also had repeated gastrointestinal bleeding that required blood transfusion. Colonoscopy showed no clear source of bleeding—inflammation and small surface ulceration of the colon, two small sores in rectal ampulla, and normal gastric fibroscopy. Parenteral nutrition and intermittent nasogastric tube were used.
Following the gradual rehabilitation and education of the patient about operating the LVAD equipment and dressing the driveline exit site, he was discharged to home. Calculated LVAD flow ranged between 5.0 and 6.0 L/min. During the entire duration of circulatory support, no LVAD suction events were detected, pump power consumption remained in the normal range (6 to 7.5 watts at pump speed 9,400 rpm), and the patient was listed for heart transplantation. We did not observe any signs of hemolysis; anticoagulation levels remained stable, and the bilirubin levels throughout postoperative follow-up were within normal range. The patient had no signs of active systemic infection.
The patient was rehospitalized in 3/2011 due to worsening of his condition. He was afebrile, fatigued, had a dry cough and brown discoloration of urine. Hemoglobinuria, an increase of inflammatory markers, and mild alteration in hepatic and renal function were detected. Initial blood cultures were negative. Transthoracic echocardiogram (TTE) and TEE imaging showed no obstruction of the inflow or outflow cannulas, but there was a decrease in flow velocities (inflow velocity = 35 cm/s; outflow velocity = 70 cm/s). The left ventricle was severely dilated and hypokinetic. The aortic valve was opening at 1:1. Even at high-speed operation (11,600 rpm), the left ventricle could not be unloaded with closure of the aortic valve. Systemic thrombolysis was considered, but a donor heart became available (patient was listed as an urgent candidate) and heart transplantation was performed in 4/2011. Examination of the explanted LVAD revealed thrombotic-like obstruction of the outflow cannula (Figures 1 and 2). Histopathologic examination and microbiological culturing of the mass have showed extensive fungal growth (Figure 3). The thrombus showed fibrinous debris, scattered inflammatory cells, and hyphae with the presence of Aspergillus species.
The patient was discharged from the hospital eight weeks after the transplantation. During the first 12 months, patient was repeatedly hospitalized due to soft tissue wound infections. Treatment consisted of soft tissue debridement and V.A.C.® Therapy. Candida albicans was culture-confirmed in multiple samples. Therefore, the patient was aggressively treated with antifungal therapy in the first three months with intrakonazol and then treated for the next nine months with fluconazol. Lower-dose corticosteroid protocol with 5 mg of prednisone daily was administered. After one year, conversion from sirolimus to everolimus was made because of early signs of coronary artery disease in the donor heart. During the two years follow-up, the patient was monitored according to our institutional protocol with regular cardiac biopsies and echocardiogram examinations, without any signs of serious complications.