Case report:
A previously fit and well 29 years old female, presented to our hospital
with gradually progressive shortness of breath and pedal oedema, after
giving birth to a child 2 months ago. 2D Echo revealed an ejection
fraction less than 10% with dilated ventricles. A diagnosis of
peripartum cardiomyopathy was made and she was commenced on heart
failure medications. Patient had poor response to medical management and
suffered a cardiac arrest in the hospital. Post successful
resuscitation, it was decided to consider her for heart transplant.
Considering the COVID epidemic and paucity of available donors, it was
decided to support her mechanically with a left ventricular assist
device (LVAD). After an uneventful LVAD (HVAD, HeartWare, Medtronics
Inc, Minnesota MN, USA) implantation via midline sternotomy and standard
cardiopulmonary bypass, device was activated and the revolutions on the
pump were steadily increased to 2600 RPM for de-airing on
cardiopulmonary bypass. The power on the LVAD device increased to a
maximum of 7.5 Watts and the flows dropped. As the de-airing proceeded a
suspicious hyper-echoic mass was noted in the left atrium on TEE leading
to confusion of a LA clot. Inversion of left atrial appendage was
suspected since the pre-CPB trans-esophageal echocardiogram showed no LA
clot and it was unlikely that a new clot would form in an anticoagulated
patient on CPB. The LVAD flows were reduced and re-examination of the
left atrium by the surgeon revealed an inverted appendage, which was
promptly everted with help of a forceps. LA mass disappeared, LVAD flows
stabilised and the power utilization immediately dropped to 3.2 Watts.
The patient made an uneventful recovery and was discharged from the
hospital within 2 weeks of surgery.