L.B. is a 62-year-old man with a long history of coronary artery disease and heart failure who has undergone multiple coronary bypass surgeries. He now has an ejection fraction of 25% and intractable ventricular tachycardia despite medical management. Due to the risks of ablation, the team is considering options like hospice care, cardiac transplantation, VAD implantation, or VAD exchange to treat his advanced heart failure. A cardiac catheterization revealed multiple occluded arteries and stenoses. Given his medical history and surgical history, the team must determine the best treatment approach for his condition.

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