Explant of Heartware Biventricular Assist Devices Following Myocardial Recovery After Peripartum Cardiomyopathy

A 37-year-old female developed acute pulmonary oedema at parturition and required emergency caesarean section. Transthoracic echocardiography demonstrated severe global systolic dysfunction (left ventricular ejection fraction [LVEF] <10%), severe right ventricular (RV) systolic dysfunction with fractional area change of 5.9%, RV strain of –3.5% and no significant valvular dysfunction. Peripheral veno-arterial extracorporeal membrane oxygenation was commenced for cardiopulmonary support. HeartWare biventricular assist devices (BiVAD) were implanted 8 days later, as a bridge to heart transplantation. A high level of sensitisation precluded subsequent acceptance of multiple suitable allografts. Eight months post–BiVAD implantation, an acute increase in right ventricular assist device (RVAD) flows/power was noted despite appropriate anticoagulation. Transoesophageal echocardiography revealed extensive thrombus formation around the RVAD inflow cannula. Systemic thrombolysis was given with resolution of abnormal RVAD parameters. However, significant RVAD thrombosis recurred, requiring repeated thrombolysis. In light of the clinical course, assessment for cardiac recovery was performed, with a view for BiVAD explant. Transthoracic echocardiography demonstrated low normal LV systolic function, LVEF of 50%, mild-moderate RV systolic dysfunction with RV free-wall tethering, and RV fractional area change of 28%. Contrast dobutamine stress echocardiography confirmed RV contractile reserve (RVOT VTI increased from 8 to 14 cm, RV free-wall strain –8.1% to –13.7%). The patient underwent successful BiVAD explant 13 months after implantation. At discharge, LVEF was 52% with mild RV systolic dysfunction (TAPSE 13 mm, RV S’ 6.5 cm, fractional area change 31%). Peripartum cardiomyopathy is a potentially reversible condition. BiVAD explant for myocardial recovery is very rare. Pump thrombosis is a complex and potentially fatal complication of VAD therapy and can develop despite appropriate anticoagulation. View Large Image Figure Viewer Download Hi-res image