A 51-year-old man who exercised regularly to maintain cardiac function following a diagnosis of low ejection fraction and non-ischemic cardiomyopathy experienced 3 arrests and 1 stroke within a year.
The patient, who had a defibrillator implanted in 2016, experienced his first cardiac arrest a few months later when the device shocked his heart during a workout at a gym. Despite adjustments to the device, the patient experienced a second arrest a few months later at the same gym. Duke heart surgeon Jeffrey G. Gaca, MD, who was working out nearby, revived him at the workout facility.
A defibrillator with cardiac resynchronization capacity was inserted to replace the standard defibrillator, but the patient arrested again when he was a passenger in a car. A nearby motorist performed CPR. He was rushed to the Duke Hospital emergency department in extreme distress and with persistent life-threatening cardiac arrhythmias.
A multidisciplinary team decided to support the patient with extracorporeal membrane oxygenation (ECMO) to stabilize circulation and allow time for assessment. The team attempted to treat his persistent arrhythmia with emergency catheter ablation. During the procedure, the patient experienced a stroke, leaving him with left-sided motor deficits.
Questions: Given the patient’s history, repeated arrests, and stroke, what immediate care was required? What long-term options were considered?
Answers: Following the stroke, Duke heart specialists determined that his other major organ systems were in good condition. The ECMO device was replaced with a temporary heart-assist device. After more than 3 months of intensive rehabilitation with this device, the patient underwent a successful transplant. He spent more than 6 months in Duke facilities but was discharged in good condition from a post-transplant rehabilitation program.
Jacob N. Schroder, MD, who performed the transplant, said the heart team’s rehabilitation efforts restored the patient’s strength and reduced his risk factors. The patient’s personal commitment to recovering was a key factor in the surgical team’s decision to pursue transplant.
“This is a patient who spent 140 days in intensive care with 4 tubes pumping his blood,” Schroder says. “He was not always feeling his best. He had down days, certainly, but our whole team worked to get him through.”
The efforts of physical and occupational therapist Kenneth Gold, PT, and his colleagues contributed significantly to the patient’s ability to reach a level of rehabilitation that allowed him to undergo transplant, Schroder says.
The scarring caused by the bi-ventricular device and the presence of the large cannulas created technical surgical challenges, but the transplant surgery was relatively uneventful, the surgeons say.
Schroder praised the heart failure team for their collective effort to support the patient during rehabilitation and recovery. “This is an extreme case, but it’s the sort of teamwork that occurs every day on behalf of our patients by many people—the heart failure team, ICU nurses, floor nurses, cardiac surgery physical therapists, and many others.”