The patient was implanted with a left ventricular assist device (lvad) on (b)(6) 2017.It was reported that the patient experienced right heart failure and required placement of a right ventricular extracorporeal life support (ecls) device on (b)(6) 2017.Post-operatively the patient improved and was able to be weaned off inotropes and was cycling between continuous positive airway pressure (cpap) and synchronized intermittent-mandatory ventilation (simv) in preparation for extubation.On (b)(6) 2017, there was a sudden decrease in lvad flow, and the patient¿s blood pressure dropped from a mean of 80 mmhg to 30 mmhg over a period of about 10 minutes.A unit of iv gelafundin was started.The lvad and the right heart ecls devices both sounded low flow alarms.The patient then suddenly became asystolic despite vvi pacing with the output at maximum.The patient¿s blood pressure and pump flows had been normal the whole day up until this event.The patient became unresponsive and no lvad flow was observed.Resuscitation with cpr commenced and the ventilator oxygen was increased to 100%.It was reported that approximately one-third of the ecls pump chamber was foamy with air.It was not known if the ecls pump was spinning at the time.The customer reported that the venous cannula was still in place and all the connections were still tight.The clinicians reported that the air could have come from the central venous line when the gelafundin was being infused.Despite resuscitation efforts, there was no spontaneous return of rhythm, pulse or breathing, and the pupils were fixed and dilated.Cpr was stopped and the patient expired.No additional information was provided.
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