Esmark elastoplasty for bleeding ventricular assist device outflow graft associated with severe coagulopathy.

摘要

Severe coagulopathy is a common entity during biventricu-lar assistance and is particularly difficult to deal with when using bivalirudin as an anticoagulant. Resultant severe coagulopathy can causes relentless bleeding, even from needle holes and graft interstices. We report the use of Esmark (Advanced Medical Designs, Marietta, Ga) as an clastoplas-tic bandage to tamponade bleeding from a ventricular assist device outflow graft. A 34-year-old woman with a history of right lower extremity osteosarcoma had adriamycin-induced cardiomyop-athy. After long-term clinical stability, pregnancy resulted in decompensation, premature loss of pregnancy, and placement of a Tandemheart (Cardiac Assist, Inc, Pittsburgh, Pa) percutaneous left ventricular assist device (LVAD). After improvement and weaning from the device, hemody-namic decompensation again occurred, prompting redo percutaneous LVAD placement and surgical referral for long-term bridge to transplantation therapy. Biventricular assistance was deemed necessary. Secondary to heparin-in-duced thrombocytopenia, bivalirudin was used for cardio-pulmonary bypass, with activated clotting times reaching as high as 700 seconds. A Heartmate II Axial flow device (Thoratec Corp, Pleasanton, Calif) was placed in the left ventricle-to-aorta configuration. The Tandemheart pump previously used as the percutaneous LVAD was recycled on the operative field and used as a right ventricular assist device with percutaneous right atrial inflow and outflow to the pulmonary artery.