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Patil S, Ahmad D, Shah K, Vishnevsky A, Ruggiero NJ, Rajapreyar IN, Rame JE, Alvarez RJ, Rajagopal K, Entwistle JW, Massey HT, Tchantchaleishvili V. Outcomes of outflow graft stenting in HeartMate 3 left ventricular assist devices: A systematic review and individual patient data meta-analysis. Artif Organs 2024; 48:577-585. [PMID: 38577853 DOI: 10.1111/aor.14736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 01/20/2024] [Accepted: 02/16/2024] [Indexed: 04/06/2024]
Abstract
PURPOSE LVAD outflow graft stenosis continues to remain prevalent with a high complication rate. We sought to pool the existing evidence on indications, utilization patterns, and outcomes of transcatheter interventions for outflow graft stenosis in the HeartMate 3 LVAD. METHODS An electronic search was performed to identify all studies in the English literature reporting on HeartMate 3 LVAD outflow graft stenting. Patient-level data were extracted for analysis. RESULTS Thirteen published reports and one unpublished case comprising a total of 28 patients were included. Median patient age was 68.5 years [Interquartile range: 58, 71] and 25.9% (7/27) were female. Dyspnea [60.7% (17/28)] was the most common presenting symptom. Low flow alarms were present in 60% (15/25) of patients. Findings included external compression [35.7% (10/28)], graft twist [21.4% (6/28)], graft twist and external compression [14.3% (4.28)], intraluminal thrombus [10.7% (3/28)], graft twist and intraluminal thrombus [3.6% (1/28)], and pseudoaneurysm of outflow graft [3.6% (1/28)]. Median time from LVAD implantation to stenting was 2.1 years [1.4, 3]. Immediate flow normalization after stenting was observed in 85.7% (24/28). The 30-day mortality was 12% (3/25). Overall mortality was 12% (3/25) at a median follow-up of 3.9 months [1, 17]. CONCLUSION Outflow graft stenting in the HeartMate 3 LVAD appears to be a reasonable treatment option for outflow graft stenosis, with low overall rates of complications and mortality. Further refinement of indications and approaches may improve outcomes.
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Affiliation(s)
- Sanath Patil
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Danial Ahmad
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Kishori Shah
- The Lawrenceville School, Lawrenceville, New Jersey, USA
| | - Alec Vishnevsky
- Division of Cardiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Nicholas J Ruggiero
- Division of Cardiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Indranee N Rajapreyar
- Division of Cardiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - J Eduardo Rame
- Division of Cardiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Rene J Alvarez
- Division of Cardiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Keshava Rajagopal
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - John W Entwistle
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Howard T Massey
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Takla A, Eid F, Elbanna M, Eid MM, Joshi A, Bitar A, Lydon R, Feitell S. Percutaneous Intervention of LVAD Outflow Graft Obstruction and Thrombosis. Methodist Debakey Cardiovasc J 2024; 20:9-13. [PMID: 38618610 PMCID: PMC11011953 DOI: 10.14797/mdcvj.1360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 02/20/2024] [Indexed: 04/16/2024] Open
Abstract
Left ventricular assist devices serve as a salvage therapy for patients with advanced heart failure. Complications such as thrombosis and obstruction can lead to acute device malfunction, posing significant clinical risks. A multidisciplinary approach is crucial for management. Few cases in the literature have demonstrated the safety and efficacy of percutaneous intervention, which holds significant value due to its less invasive nature and minimal risk of morbidity, especially in high-risk surgical patients.
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Affiliation(s)
- Andrew Takla
- Rochester General Hospital, Rochester, New York, US
| | - Fahad Eid
- Unity Hospital, Rochester, New York, US
| | | | | | - Akshay Joshi
- Rochester General Hospital, Rochester, New York, US
| | | | - Ryan Lydon
- Rochester General Hospital, Rochester, New York, US
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Mejia E, Cole J, Soszyn N, Auerbach S, Morgan GJ. Percutaneous Stenting of a Stenotic Berlin Heart Outflow Cannula Graft in a 2 Year Old Child. ASAIO J 2023:00002480-990000000-00365. [PMID: 38039507 DOI: 10.1097/mat.0000000000002112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2023] Open
Abstract
Left ventricular assist device (LVAD) outflow obstruction is a rare complication of long-term LVAD support. We present the first case of successful percutaneous stent implantation in a pediatric patient with LVAD outflow obstruction.
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Affiliation(s)
- Ernesto Mejia
- From the Department of Pediatric Cardiology, The Heart Institute, Children's Hospital Colorado, University of Colorado, Aurora, Colorado
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4
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Elbayomi M, Weyand M, Uder M, May MS, Steger K, Roth J, Tandler R. Endovascular stenting of an HVAD™ outflow graft pseudoaneurysm that exerts compression and kinking stenosis on the soft portion of the prosthesis. Clin Case Rep 2023; 11:e7349. [PMID: 37215974 PMCID: PMC10196405 DOI: 10.1002/ccr3.7349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 04/21/2023] [Accepted: 04/30/2023] [Indexed: 05/24/2023] Open
Abstract
Key Clinical Message Complex presentations of MCS patients may necessitate a multidisciplinary approach involving HF cardiologists, CT surgeons, advanced cardiac imagers, and interventional cardiologists in order to define the optimal management strategy. Abstract Left ventricle assist devices (LVADs) provide life-sustaining treatment for patients with terminal heart failure, but their intricacy allows for complications. One complication is LVAD outflow graft obstruction due to the graft's intraluminal thrombus or extraluminal compression. It may be treated endovascularly with stenting. We report an endovascular stenting of an outflow tract in HVAD™ (HeartWare Inc.) due to a pseudoaneurysm causing compression and kinking stenosis.
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Affiliation(s)
- Mohamed Elbayomi
- Department of Cardiac SurgeryFriedrich‐Alexander‐University Erlangen‐NurembergErlangenGermany
| | - Michael Weyand
- Department of Cardiac SurgeryFriedrich‐Alexander‐University Erlangen‐NurembergErlangenGermany
| | - Michael Uder
- Department of RadiologyFriedrich‐Alexander‐University Erlangen‐NurembergErlangenGermany
| | - Matthias S. May
- Department of RadiologyFriedrich‐Alexander‐University Erlangen‐NurembergErlangenGermany
| | - Katrin Steger
- Department of Cardiac SurgeryFriedrich‐Alexander‐University Erlangen‐NurembergErlangenGermany
| | - Jan‐Peter Roth
- Department of RadiologyFriedrich‐Alexander‐University Erlangen‐NurembergErlangenGermany
| | - Rene Tandler
- Department of Cardiac SurgeryFriedrich‐Alexander‐University Erlangen‐NurembergErlangenGermany
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Peters CJ, Zhang RS, Vidula MK, Giri J, Atluri P, Acker MA, Bermúdez CA, Levin A, Urgo K, Wald J, Mazurek JA, Hanff TC, Goldberg LR, Jagasia D, Birati EY. Durable Left Ventricular Assist Device Outflow Graft Obstructions: Clinical Characteristics and Outcomes. J Clin Med 2023; 12:jcm12062430. [PMID: 36983430 PMCID: PMC10058609 DOI: 10.3390/jcm12062430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 03/06/2023] [Accepted: 03/19/2023] [Indexed: 03/30/2023] Open
Abstract
PURPOSE We report on the clinical course and management of patients supported with durable implantable LVADs who developed outflow graft obstructions at a large academic center. METHODS We performed a retrospective review of patients receiving LVAD support from 2012 through 2020. Patients who developed an outflow graft obstruction diagnosed by computed tomography angiography (CTA) or angiogram were identified, and patient characteristics and outcomes were reported. RESULTS Of the 324 patients supported by LVAD at our institution, 11 patients (3.4%) were diagnosed with outflow graft obstructions. The most common presentation was low flow alarms, which was present in 10/11 patients, and the remaining patient presented with lightheadedness. Patients had minimal LDH elevation with 8/11 presenting with less than 2-fold the upper limit of normal. Transthoracic echocardiograms were not diagnostic, but CTA enabled non-invasive diagnoses in 8/11 of the patients. Three patients with extrinsic compression of the outflow graft successfully underwent endovascular stent placement, and three patients with outflow cannula kinks received supportive care. Of the five patients diagnosed with intraluminal thromboses, one received a heart transplant, one underwent an outflow graft revision, and three received supportive care due to comorbidities. CONCLUSION Outflow graft obstructions remain a rare, but serious complication. The true prevalence of this entity is likely underestimated due to the non-specific clinical presentation. CTA is a pivotal non-invasive diagnostic step. Patients with external compression were successfully treated with endovascular stenting.
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Affiliation(s)
- Carli J Peters
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Robert S Zhang
- Division of Cardiovascular Medicine, NYU Langone Health, New York, NY 10016, USA
| | - Mahesh K Vidula
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Jay Giri
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Pavan Atluri
- Cardiothoracic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Michael A Acker
- Cardiothoracic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Christian A Bermúdez
- Cardiothoracic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Allison Levin
- Division of Cardiology, Duke University Medical Center, Durham, NC 27710, USA
| | - Kim Urgo
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Joyce Wald
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Jeremy A Mazurek
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Thomas C Hanff
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - Lee R Goldberg
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Dinesh Jagasia
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Edo Y Birati
- The Lydia and Carol Kittner, Lea and Benjamin Davidai Cardiovascular Division, Tzafon (Poriya) Medical Center, Azrieli Faculty of Medicine, Bar-Ilan University, Ramat Gan 5290002, Israel
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Gasecka A, Szymanski M, Voskuil M, van Laake LW, Ramjankhan F, Kraaijeveld AO. Percutaneous management of left ventricular assist device outflow graft obstruction. EUROINTERVENTION 2022; 18:e353-e354. [PMID: 35040781 PMCID: PMC9912952 DOI: 10.4244/eij-d-21-00899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Aleksandra Gasecka
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Mariusz Szymanski
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Michiel Voskuil
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Linda W. van Laake
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Faiz Ramjankhan
- Department of Cardiothoracic Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Adriaan O. Kraaijeveld
- Department of Cardiology, Utrecht University Medical Center, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
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7
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Gasecka A, Voskuil M, de Waal EEC, Oerlemans MIFJ, Ramjankhan F, van Laake LW, Kraaijeveld AO. A routine intervention in a highly unusual vessel. Neth Heart J 2021; 30:182-183. [PMID: 34528176 PMCID: PMC8881560 DOI: 10.1007/s12471-021-01635-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- A Gasecka
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - M Voskuil
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - E E C de Waal
- Department of Anaesthesiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - M I F J Oerlemans
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - F Ramjankhan
- Department of Cardiothoracic Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - L W van Laake
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - A O Kraaijeveld
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands.
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8
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Milwidsky A, Alvarez Villela M, Wiley J, Sanina C, Patel SR, Sutton N, Latib A, Sims DB, Forest SJ, Shin JJ, Farooq MU, Goldstein DJ, Jorde UP. Outflow graft obstruction in patients with the HM 3 LVAD: A percutaneous approach. Catheter Cardiovasc Interv 2021; 98:1383-1390. [PMID: 34047456 DOI: 10.1002/ccd.29785] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/04/2021] [Accepted: 05/09/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND The use of the HeartMate 3 (HM3) left ventricular assist device (LVAD) is expanding. Despite being associated with lower rates of adverse events and increased survival, outflow graft obstruction (OGO) has been reported in patients with HM3. The incidence and best management of this serious complication remain unclear. METHODS We describe six cases of HM3 OGO occurring in five patients in our institutional HM3 cohort. Four cases underwent computed tomography angiography and in two percutaneous angiography was directly performed to confirm the diagnosis. In four cases, percutaneous repair of the OG was performed using common interventional cardiology (IC) techniques. RESULTS Our institutional incidence of OGO was 7% (event rate of 0.05 per patient year); much higher than the previously reported incidence of 1.6%. All cases occurred in the bend relief covered segment. Only two patients had apparent OG twisting, and in two, OGO occurred despite placement of an anti-twist clip at the time of implant. External compression seems to play a role in most cases. Balloon "graftoplasty" and stent deployment via the femoral artery alleviated the obstruction and normalized LVAD flow in all patients who underwent percutaneous repair. The use of self-expanding stents allowed for downsizing of the procedural access site to 10 Fr. No serious procedure-related complications occurred. CONCLUSION OGO is common in HM3 patients, external compression due to biomaterial accumulated surrounding the OG is a common etiology. Percutaneous repair using standard IC techniques is safe and feasible in cases of compression with or without partial twisting.
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Affiliation(s)
- Assi Milwidsky
- Division of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA.,Division of Cardiology Tel-Aviv Medical Center affiliated with Sackler School of Medicine in Tel-Aviv University, New York, New York, USA
| | - Miguel Alvarez Villela
- Division of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA
| | - Jose Wiley
- Division of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA
| | - Cristina Sanina
- Division of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA
| | - Snehal R Patel
- Division of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA
| | - Nicole Sutton
- Division of Pediatric Cardiology, Department of Pediatrics, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Azeem Latib
- Division of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA
| | - Daniel B Sims
- Division of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA
| | - Stephen J Forest
- Department of Cardiovascular and Thoracic Surgery, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA
| | - Julia J Shin
- Division of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA
| | - Muhammad U Farooq
- Division of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA
| | - Daniel J Goldstein
- Department of Cardiovascular and Thoracic Surgery, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA
| | - Ulrich P Jorde
- Division of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA
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