347. Case Report: Heartmate 3 with a Side of Mustard – Medical University of South Carolina

CardioNerds (Dr. Josh Saef and Dr. Sumeet Vaikunth) join Dr. Sheng Fu, Dr. Payton Kendsersky, and Dr. Aniqa Shahrier from the Medical University of South Carolina for some off-shore fishing. They discuss the following featuring a patient with D-TGA and Eisenmenger’s syndrome treated with a Heartmate 3. Expert commentary was provided by Dr. Brian Houston. The episode audio was edited by student Dr. Adriana Mares.



A 39-year-old woman with a history of D-transposition of the great arteries (D-TGA) with prior atrial switch repair (Mustard) was admitted from the clinic with cardiogenic shock. She underwent right heart catheterization which demonstrated elevated biventricular filling pressures and low cardiac index. An intra-aortic balloon pump was placed, and the patient was evaluated for advanced therapies. A liver biopsy showed grade 3 fibrosis, which, in combination with her shock state, made her a high-risk candidate for isolated heart or combined heart-liver transplantation. After a multi-disciplinary discussion, the patient underwent a Heartmate III left ventricular assist device (LVAD) implant in her systemic right ventricle. Although she did well post-operatively, she was admitted after a month with recurrent cardiogenic shock, with imaging showing her inflow cannula had become perpendicular to the septum.  The patient and family eventually decided to pursue comfort measures, and the patient passed.







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Case Media - D-TGA and Eisenmenger’s syndrome treated with a Heartmate 3





















Pearls - D-TGA and Eisenmenger’s syndrome treated with a Heartmate 3




Early diagnosis of cyanotic congenital heart disease is paramount for treatment and prevention of future complications.



Adult congenital heart disease requires a multi-disciplinary team for management in consultation with an adult congenital cardiology specialist.



Eisenmenger syndrome is related to multiple systemic complications and has a high rate of mortality.



Advancement in PAH medical management can offer noninvasive treatment options for some patients.



Transthoracic echocardiography is the cornerstone for diagnosis. Other modalities (e.g. cardiac CT, cardiac MRI, invasive catheterization) can aid in diagnosis and management.




Pearls - D-TGA and Eisenmenger’s syndrome treated with a Heartmate 3




While advances in pediatric surgery have allowed many patients born with congenital heart disease to survive into adulthood, adult congenital heart disease (ACHD) patients are complex and prone to numerous adverse sequalae including arrhythmias, heart failure, valvular disease, and non-cardiac organ dysfunction.



Heart failure can be a challenging presentation in ACHD patients due to a longstanding history of clinical compensation.



Their unique and complex anatomy, as well as highly variable clinical presentation, present unique challenges when it comes to advanced heart failure options such as durable left ventricular assist devices (LVAD) or transplantation.



While durable LVAD implantation is possible in patients with systemic right ventricles, anatomic compatibility is paramount and poses ongoing challenges in their management.



Goals of care discussions should be had early, as options for treatment may be limited.




Show Notes - D-TGA and Eisenmenger’s syndrome treated with a Heartmate 3



What are some common sequelae in ACHD patients?



ACHD patients are a heterogeneous population, but atrial tachycardias are extremely frequent in this patient population, often due to re-entrant pathways around surgical suture lines. These can often be treated with radiofrequency ablation while paying clos...