Background: The ultimate treatment for end stage heart failure is heart transplant. However, due to scarcity of donors clinicians opt for mechanical circulatory support as a bridge to transplant or destination therapy. Regional experience with the use of temporary biventricular assist device (BiVAD) support as a bridge to heart transplant is limited.
Case report: We report a case of a 28-year-old gentleman diagnosed with non-ischemic cardiomyopathy of familial etiology 10 years before presentation resulting in recurrent hospitalizations, complicated by non-compliance to goal-directed medical therapy and refusal of device therapy. He presented to an outside hospital with cardiogenic shock (CS) (cold and wet phenotype, SCAI stage C) and was started on furosemide infusion, ionotropic and vasopressor support. During his stay he was found to have acute hepatic and renal dysfunction. He was transferred to our hospital for advanced heart failure workup.
Upon arrival, he was in SCAI stage D CS. An echocardiogram showed biventricular failure with LVEF of 15%, severe functional MR, TR and pulmonary hypertension. Pulmonary artery catheter (PAC) was placed revealed elevated filling pressures with moderate pulmonary hypertension (mPAP 48 mmHg) and low CO/CI (1.8 l/min /1.3 l/min/m2) with PVR of 5.4 WU. He had cardiac cachexia (BMI 15 kg/m2) and multiorgan failure for which he underwent CRRT and liver biopsy which showed interstitial fibrosis. Despite being on ionotropic support and vasopressors his overall condition declined. Therefore, multidisciplinary team (MDT) discussion reached to a consensus of supporting him with peripheral VA-ECMO and IABP for LV unloading. Renal and hepatic functions as well as pulmonary pressures improved dramatically with mechanical circulatory support (MCS).
After 29 days on VA-ECMO + IABP awaiting urgent heart transplantation, and in light of severe deconditioning and ongoing risk of complications on peripheral VA-ECMO, MDT decided to upgrade MCS to temporary central BiVAD.  Aggressive nutritional support and physical rehabilitation was introduced while waiting for a suitable donor. During his stay on central BiVADs, he developed intracranial bleeding on therapeutic aPTT and seizure for which he was started on levetiracetam and we maintained a lower aPTT goal.
After 70 days of being on central BiVADs, a suitable donor became available and he underwent orthotopic heart transplant. Post-transplant course during was unremarkable with good recovery. PAC post-transplant showed normal filling pressures and cardiac output with mild pulmonary hypertension (mPAP 28 mmHg) and the first endomyocardial biopsy showed ISHLT 0R, pAMR 0.
Conclusions: Central Bi-VAD support pre-transplant is not used commonly, therefore the literature is limited. It can be used effectively as a bridge to heart transplantation in patients with biventricular failure and carries similar outcomes compared to those with LVADs.