Abstract 16077: Aortic Valve Thrombus and Acute Right Ventricular Failure in Recent Left Ventricular Assist Device Recipient: A Rare Case

Case reports of aortic root thrombus with embolism leading to right ventricular (RV) failure in patients left ventricular assist devices (LVAD) are extremely rare in the literature, and often result in significant mortality. This is a case of a 52-year-old male who recently underwent destination-therapy HeartMate 3 LVAD implantation, on chronic warfarin, with history of non-ischemic cardiomyopathy, atrial fibrillation, and heparin-induced thrombocytopenia, who presented with chest pain and dyspnea. Initial evaluation was remarkable for tachycardia, troponin of 0.7 ng/dl, BNP 705, and INR 1.68. Argatroban was initiated, along with diuresis for volume overload on examination. Transthoracic echocardiogram showed stable findings with borderline RV dysfunction. On the following day, persistent chest pain and uptrend of troponin to 34 ng/dl were concerning for acute coronary syndrome (ACS), and plans were for left heart catheterization. However, a TEE revealed partial thrombus layering in the aortic valve and sinus of Valsalva with concerns for embolization through the right coronary ostia. RV assessment showed evidence of severe dilation and acute RV failure. Patient underwent emergent RV assist device (RVAD) placement (ProtekDuo and CentriMag) by cardiothoracic surgery. After mechanical RV support, there was progressive improvement of its function, and successful RVAD decannulation was attained. The patient was recently seen in the heart failure clinic with sustained recovery. Cases of aortic root thrombus with embolism leading to ACS in LVAD patients are extremely rare. As in our case, troponin elevation, subtherapeutic INR, and aortic root thrombus, allowed early clinical recognition and appropriate management of patient’s RV failure, which is imperative for successful outcomes in LVAD patients. Aortic valve thrombus should be considered in LVAD patients presenting with ACS, and early invasive strategy without valve assessment should be cautioned.