key: cord-0078236-460vluuj
authors: Schettle, Sarah; Frantz, Robert; Stulak, John; Villavicencio, Marurico; Rosenbaum, Andrew
title: HeartWare Thrombosis Following mRNA COVID-19 Vaccination
date: 2022-05-17
journal: Mayo Clin Proc
DOI: 10.1016/j.mayocp.2022.05.010
sha: 0e6f77c1763c7e2a849417d36a6301bb68da74f6
doc_id: 78236
cord_uid: 460vluuj

nan

To the Editor: A female in her late 50's with end-stage heart failure secondary to nonischemic dilated cardiomyopathy was implanted with a HeartWare (HeartWare, Framingham, MA) left ventricular assist device (LVAD) as bridge to transplant. She was not known to have a hypercoagulable condition, and in the 6 years supported on LVAD prior to presentation, had not experienced power elevations, high watts alarms, or any evidence of hemolysis/thrombosis or hemocompatibility-related adverse event on LVAD. She was not actively listed for transplant due to personal preference.

She received the initial series of two COVID-19 vaccinations with the BNT162b2 (Pfizer-BioNTech COVID mRNA vaccine) and underwent COVID-19 booster 7 months later. She had no immediate reaction and described only arm soreness following the booster. Eight days later, she noted an episode of tea-colored urine but did not notify the LVAD team. Eleven days after the booster, the LVAD team was contacted with concerns of chest pressure and high watts alarms and patient reported to the emergency department. There, an episode of hematuria was noted, INR was 2.9, and metabolic panel returned hemolyzed. All international normalized ratio (INR) readings in the 2 months preceding admission were between 2.4-3.9; none were subtherapeutic. She had been compliant with daily aspirin 325 mg daily since implantation.

Upon admission, powers were noted to be elevated and initial lactate dehydrogenase (LDH) was over 3000 U/L. Pump thrombosis was diagnosed and United Network for Organ Sharing (UNOS) listing status was upgraded appropriately. Over the hospitalization course, despite adequate antithrombotic therapy (tirofiban, heparin, and aspirin 325 mg BID) powers continued to rise (Figure 1a & 1b) and LDH remained markedly elevated (Fig 1b) . HeartWare powers and estimated flows exceeded 20 W and 10 L/min, respectively and LDH levels peaked at 4458 U/L (Figure 1b) . Given concerns for imminent pump stoppage, she underwent exchange from HeartWare to HeartMate 3 (Thoratec, Pleasanton, CA) 10 days after admission with HeartWare device demonstrating thrombus within the pump housing (Figure 1c) .

COVID mRNA vaccinations are broadly recommended for all patients, including those supported on LVAD therapy, with exceedingly low risk of complications after vaccination. 1 Yet, reports have described increased arterial thromboembolism risk and cerebral venous sinus thrombosis risk following Pfizer-BioNTech vaccine 2 and an increased VTE signal after the first Pfizer-BioNTech vaccine dose. 3 These observations highlight the possibility that a proinflammatory milieu post-vaccination may increase the risk of thrombosis on rare occasions.

Vaccine-induced thrombotic thrombocytopenia (VITT) and thrombosis with thrombocytopenia syndrome (TTS) are phenomena that have been reported following COVID vaccinations with pathophysiologic mechanisms that are presently being studied. 4,5 Our patient received a Pfizer-BioNTech vaccine 8 days prior to report of tea-colored urine, had a platelet count <150 x10(9)/L prior to device exchange, and had confirmed device thrombosis, but did not complete all the testing required to make either diagnosis prior to device exchange, raising consideration for potential risk of thrombosis for patients on the TTS spectrum.

Additional reports from other centers with LVAD-supported patients who receive COVID vaccinations may help elucidate a causality and begin to estimate a frequency of what is suspected to be a rare phenomenon. This experience does not represent a contraindication to vaccination; rather, it highlights the importance of LVAD clinicians to remain vigilant and avoid neglecting an LDH rise or reports of dark urine in the context of recent COVID-19 vaccination among LVAD-supported patients. 

Myocarditis With COVID-19 mRNA Vaccines