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Twin Pregnancy With A Left Ventricular Assist Device
Abstract Number: SUN-14
Abstract Type: Case Report/Case Series
Introduction: A 28 year old G4P2 woman with a left ventricular assist device (LVAD) presented with an eleven week twin pregnancy. Non-ischemic heart failure of unknown etiology was diagnosed in 2010 and an LVAD was placed in 2012 as a bridge to transplant eligibility. She was New York Heart Association (NYHA) Class IV with a left ventricular ejection fraction (LVEF) of 13%. Clinical course after LVAD placement was complicated by LVAD thrombosis, device-related and systemic infections, two pump replacements, and a hemorrhagic stroke requiring craniotomy. Obstetrical history included two prior Cesarean deliveries, both preceding the diagnosis of heart disease, and a therapeutic abortion amidst severe heart failure before LVAD placement.
Description: Despite appropriate use of contraception, a CT scan of her abdomen meant to investigate thrombus extension after admission for a DVT revealed a first trimester twin pregnancy. An ultrasound demonstrated diamniotic dichorionic twins at 11 weeks’ gestational age. Despite recommendation to terminate, she elected to continue the pregnancy. Before discharge, her LVAD was interrogated and was running at a speed of 9400 rpm, a flow of 6.9L/min and power of 6.8 watts. The pulsatility index was 4.4. Multidisciplinary plans were being made regarding adjustment of LVAD settings to accommodate physiologic changes of pregnancy. Nine days after discharge, she returned severely somnolent with a focal headache. She had a supratherapeutic INR at 4.7 and was diagnosed with an intracerebral hemorrhage. She underwent emergent decompressive craniotomy and was transferred to the intensive care unit (ICU) intubated and requiring vasopressors. Her condition remained critical and four days later she had a spontaneous abortion in the ICU. A prolonged ICU stay ensued, complicated by several nosocomial infections, arrhythmias, LVAD thrombosis, and progression of her intracranial hematoma. After 43 days, her intracranial hematoma had expanded markedly, and anticoagulation was held. Progressive LVAD thrombosis ensued, resulting in device failure. She was transitioned to comfort care and her LVAD was disabled. She died from hyperkalemic cardiac arrest five days later.
Discussion: This is the first case report to document the death of a parturient secondary to LVAD related complications. There are currently two case reports of successful pregnancies in parturients with LVADs. It is not known what effect twin pregnancy has on LVAD related complications, nor is it known whether an LVAD can be reliably modified to accommodate the physiologic changes of pregnancy and support the hemodynamic demands of the fetus(es). Significant concern arises with the appropriate diagnosis and management of pregnancy related complications such as thrombosis and preeclampsia and safe delivery planning in a fully anticoagulated patient.
References: 1) S LaRue et al. Obstet Gynecol. 2011 Aug;118:426-8; 2) DB Sims et al. Jhealun. 2011 June;10:1065-67