we report the airway complications of total artificial heart ( tah ) and the use of an endoscopic retrieval basket to remove the blood clot from the airway . the patient was a 52-year - old african american male with a past medical history of nonischemic cardiomyopathy ( ejection fraction of 15% ) from a viral infection , coronary artery disease with implantable cardioverter , diabetes mellitus , and chronic kidney disease stage iii who was admitted with decompensated heart failure . the patient had weight gain , renal failure , and congested liver due to heart failure . the patient continued to deteriorate clinically , requiring dialysis for renal failure and mechanical ventilation and venoarterial extracorporeal membrane oxygenation ( ecmo ) for hypoxic respiratory failure and biventricular failure . on day 8 , he underwent tah implantation and ecmo decannulation . the patient required almost daily platelet transfusions for thrombocytopenia due to worsening liver dysfunction . despite being coagulopathic , low dose bivalirudin was initiated with a partial thromboplastin time goal of 4060 s given the high increased risk of clot in the setting of a tah . his respiratory status was stable until hospital day 14 when he developed acute onset hypoxia . he underwent bronchoscopy , which demonstrated severe mucous plugging of the left bronchus . during bronchoscopy , a left main stem airway cast was removed with subsequent expansion of his left lung . on hospital day 19 , the patient developed increased peak airway pressures . he became difficult to ventilate and experienced sudden onset loss of tah flows and resultant hypotension . a large blood clot was pulled through the endotracheal tube ( ett ) using a 14-french suction catheter with the return of ventilation and improvement in tah flows . an emergent bronchoscopy revealed a large clot at the carina spilling from left to right main bronchus . the clot was noted to cause air trapping through a ball - valve phenomenon allowing air to enter but not escape [ figure 1a and b ] . a roth net which is an endoscopic retrieval basket [ figure 2 ] was introduced through the therapeutic bronchoscope . roth net had a sheath diameter of 2.5 mm , length of 230 cm , and net size of 3 cm  6 cm . the distal end of the clot was encased in the net , and the entire basket with the clot was slowly pulled out . due to the large size of the clot , we were unable to retrieve the clot through the ett . therefore , the ett , bronchoscope , roth net and clot were all removed as one unit . an 8.5 mm ett was replaced along with a left main stem bronchial blocker to tamponade the bleeding . on inspection , the clot was found to be 14 cm in length by 5 cm at the widest point [ figure 3 ] . unfortunately , the patient 's multiorgan failure continued to worsen , and on hospital day 23 , the patient 's family decided to withdraw care . a roth net which is an endoscopic retrieval basket [ figure 2 ] was introduced through the therapeutic bronchoscope . roth net had a sheath diameter of 2.5 mm , length of 230 cm , and net size of 3 cm  6 cm . the distal end of the clot was encased in the net , and the entire basket with the clot was slowly pulled out . due to the large size of the clot , we were unable to retrieve the clot through the ett . therefore , the ett , bronchoscope , roth net and clot were all removed as one unit . an 8.5 mm ett was replaced along with a left main stem bronchial blocker to tamponade the bleeding . on inspection , the clot was found to be 14 cm in length by 5 cm at the widest point [ figure 3 ] . unfortunately , the patient 's multiorgan failure continued to worsen , and on hospital day 23 , the patient 's family decided to withdraw care . our case is the reflection of potential complications that may arise in patients who are on mechanical circulatory support devices in the intensive care unit . as more and more of these procedures are being done throughout the country , it is pertinent that these complications be kept in mind . managing these complications could be difficult ; we , in our case , presented the novel use of roth net to remove the clot from the airways . the clot was causing a  ball - valve  mechanism and thus creating lung hyperinflation with a subsequent effect on gas exchange and the risk of barotrauma to the lungs . the tah has been approved by food and drug administration as a bridge to transplant in patients awaiting cardiac transplantations . risk of early bleeding is not uncommon in patients with total artificial heart and therefore delayed sternal closure is preferred in many centers . other complications such as mediastinal tamponade and renal failure could occur due to altered physiology . bleeding in the airway can be severe and can form a clot and the cast of the airway which could be life threatening . removing the clot from the airway can be a tedious process . use of roth net is a new technique which can help remove the clot in the safest and fastest way . airway bleeding with subsequent air trapping through a ball - valve phenomenon is an emergent complication which can be of dire consequences if not recognized early and treated .
the total artificial heart is the mechanical device which is used as a bridge to the heart transplant in patients with biventricular failure . due to the mechanical nature of the device , 
 patients receiving total artificial heart ( tah ) require to be on anticoagulation therapy . 
 hemorrhage and coagulopathy are few of the known complications of tah .