Skip to main content

The ‘Inextricabilis Syndrome’: a case with no solution


We describe a case of a 58-year-old man with cardiogenic shock who underwent triple vessel coronary artery bypass and a left ventricular assist device (LVAD) implantation. His course was complicated by stroke, worsening mitral regurgitation, aortic regurgitation, and multiple cardiac thrombi while on the device. We provide the details of the patient’s hospital course, management, and echocardiographic findings. We also discuss the utility of echocardiography before LVAD insertion and its role for continued monitoring after insertion.

Learning points

  • Ventricular assist devices (VADs) are used as bridge to decision, transplant, recovery, or destination therapy in patients with advanced heart failure and cardiogenic shock.

  • VADs improve survival and the quality of life but have significant associated complications.

  • Echocardiography plays an essential role before VAD insertion and for postoperative cardiac monitoring. Information provided by echocardiography is used in device selection, consideration for corrective surgical interventions, and device explantation.


  1. Sayer GT, Baker JN, Parks KA 2012 Heart rescue: the role of mechanical circulatory support in the management of severe refractory cardiogenic shock. Current Opinion in Critical Care 18 409–416. (doi:10.1097/MCC.0b013e328357f1e6

    Article  Google Scholar 

  2. Rose EA, Gelijns AC, Moskowitz AJ, Heitjan DF, Stevenson LW, Dembitsky W, Long JW, Ascheim DD, Tierney AR, Levitan RG etal 2001 Long-term use of a left ventricular assist device for end-stage heart failure. New England Journal of Medicine 345 1435–1443. (doi:10.1056/NEJMoa012175

    Article  CAS  Google Scholar 

  3. Ziemba EA, John R 2010 Mechanical circulatory support for bridge to decision: which device and when to decide. Journal of Cardiac Surgery 25 425–433. (doi:10.1111/j.1540-8191.2010.01038.x

    Article  Google Scholar 

  4. Chumnanvej S, Wood MJ, MacGillivray TE, Melo MF 2007 Perioperative echocardiographic examination for ventricular assist device implantation. Anesthesia and Analgesia 105 583–601. (doi:10.1213/01.ane.0000278088.22952.82

    Article  Google Scholar 

  5. Estep JD, Stainback RF, Little SH, Torre G, Zoghbi WA 2010 The role of echocardiography and other imaging modalities in patients with left ventricular assist devices. JACC. Cardiovascular Imaging 3 1049–1064. (doi:10.1016/j.cmg.2010.07.012

    Article  Google Scholar 

  6. John R, Long JW, Massey HT, Griffith BP, Sun BC, Tector AJ, Frazier OH, Joyce LD 2011 Outcomes of a multicenter trial of the Levitronix CentriMag ventricular assist system for short-term circulatory support. Journal of Thoracic and Cardiovascular Surgery 141 932–939. (doi:10.1016/j.jtcvs.2010.03.046

    Article  Google Scholar 

  7. Porepa LF, Starling RC 2014 Destination therapy with left ventricular assist devices: for whom and when? Canadian Journal of Cardiology 30 296–303. (doi:10.1016/j.cjca.2013.12.017

    Article  Google Scholar 

  8. Slaughter MS, Rogers JG, Milano CA, Russell SD, Conte JV, Feldman D, Sun B, Tatooles AJ, Delgado RM III, Long JW etal 2009 Advanced heart failure treated with continuous-flow left ventricular assist device. New England Journal of Medicine 361 2241–2251. (doi:10.1056/NEJMoa0909938

    Article  CAS  Google Scholar 

  9. Cowger J, Pagani FD, Haft JW, Romano MA, Aaronson KD, Kolias TJ 2010 The development of aortic insufficiency in left ventricular assist device-supported patients. Circulation. Heart Failure 3 668–674. (doi:10.1161/CIRCHEARTFAILURE.109.917765

    Article  Google Scholar 

  10. Topilsky Y, Maltais S, Oh JK, Atchison FW, Perrault LP, Carrier M, Park SJ 2011 Focused review on transthoracic echocardiographic assessment of patients with continuous axial left ventricular assist devices. Cardiology Research and Practice 2011 article ID 187434. (doi:10.4061/2011/187434.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations


Corresponding author

Correspondence to Robert J. Siegel MD.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Khachatryan, T., Beigel, R., Arsanjani, R. et al. The ‘Inextricabilis Syndrome’: a case with no solution. Echo Res Pract 1, K13–K16 (2014).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: