The complex patient vad ransplant vad exchange or hospice
- 1. The Complex Patient: VAD, Transplant, VAD Exchange, or Hospice? Team Management in Advanced Heart Failure, Cardiac Transplantation and VADs: Who Makes the Call? ACC.15 March 14, 2015 Mary Norine Walsh, MD, FACC Medical Director, HF and Cardiac Transplantation St Vincent Heart Center
- 2. L.B. 62-year-old man with a long history of coronary artery disease. He had a remote myocardial infarction and has undergone coronary artery bypass grafting twice in the past, first in 1992 and a second time in December of 2007. Most recent assessment of left ventricular systolic function by cardiac catheterization in July 2014 and recent echo demonstrated an ejection fraction of about 25%. Primary issue is that of ventricular tachycardia. NYHA II, but with intractable VT. He was hospitalized early last summer while visiting Maine. He had sustained VT at that time and was also hospitalized in December of this year. At the last episode, he underwent pace- termination. He is currently on high dose amiodarone, mexiletine and has been on these medications for some time. His Amiodarone has been down titrated primarily because he has had elevated liver enzymes. When he was hospitalized in December, discussions were had with him about ventricular tachycardia ablation. It has been felt that ablation would be very risky for him. 2
- 3. L.B. His cardiac catheterization which was done in mid July demonstrated: patent left main, an occluded LAD at the first septal branch, an occluded proximal ramus intermedius, a 50% stenosis in the circumflex proximally with a 50% stenosis in the first OM branch; the RCA was occluded at the mid vessel; the LIMA to the diagonal and sequential to the LAD was patent but the LAD was occluded after the LIMA anastomosis; a vein graft to the mid LAD which is distal and is sequential to a large ramus or high diagonal was patent with a 50% stenosis. At the anastomosis of the vein graft, the LAD had 50% narrowing as well. The vein graft to the right PDA had luminal irregularities and was not obstructed. He has never smoked cigarettes. He has had hyperlipidemia and hypertension but no diabetes. Besides his cardiac problems, his past medical history is otherwise actually pretty unremarkable. He has a little bit of BPH. He has some depression and anxiety. He has had hyperthyroidism felt to be related to Amiodarone. He consumes two alcoholic beverages daily. He has been unable to exercise. He was previously employed as a consultant. He hasn’t worked since his second CABG surgery in December of 2007. 3
- 4. L.B. 4