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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 RESULTS Thirteen published reports and one unpublished case comprising a total of 28 patients were included.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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2
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Capek L, Huber AT, Reineke D, Dobner S, Hunziker LC, Schnegg B. Outflow Graft Obstruction due to Local Aortic Dissection After Implantation of Left Ventricle Assist Device (HeartMate 3). ASAIO J 2024:00002480-990000000-00477. [PMID: 38728741 DOI: 10.1097/mat.0000000000002222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024] Open
Abstract
Left ventricular assist devices (LVADs) improve symptoms and outcomes in patients with advanced heart failure. We report the case of a patient with a freshly implanted HeartMate 3 LVAD, suffering abruptly on postoperative day 55 from pejoration of his heart failure with multiple episodes of low-flow alarm. Outflow graft obstruction (OGO) due to local aortic dissection was diagnosed with multimodality imaging. After a multidisciplinary discussion, a surgical approach was decided, and the patient benefited from a revision of his outflow graft.
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Affiliation(s)
- Lukas Capek
- From the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Adrian Thomas Huber
- Department of Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - David Reineke
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stephan Dobner
- From the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lukas Christoph Hunziker
- From the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Bruno Schnegg
- From the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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3
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Litvak A, Desai K, Narins C, Mix D. Percutaneous endovascular stenting to treat left ventricular assist device outflow graft stenosis. J Vasc Surg Cases Innov Tech 2024; 10:101430. [PMID: 38375350 PMCID: PMC10875609 DOI: 10.1016/j.jvscit.2024.101430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 01/02/2024] [Indexed: 02/21/2024] Open
Abstract
A 72-year-old woman presented with acute symptoms of congestive heart failure exacerbation and cardiogenic shock secondary to flow alarms in her HeartMate II left ventricular assist device (LVAD) placed in 2013. Her rapid deterioration required venoarterial extracorporeal membrane oxygenation placement with subsequent cardiac catheterization. A computed tomography scan corroborated 90% stenosis of the LVAD outflow graft with mural thrombus causing cardiogenic shock. A multidisciplinary team proceeded with endovascular treatment of the LVAD outflow obstruction via realignment with percutaneous angioplasty and placement of covered stent grafts. After in-hospital recovery, she was discharged to a rehabilitation facility.
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Affiliation(s)
- Aaron Litvak
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Kshitij Desai
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Craig Narins
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Doran Mix
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
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4
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Wert L, Stewart GC, Mehra MR, Milwidsky A, Jorde UP, Goldstein DJ, Selzman CH, Stehlik J, Alshamdin FD, Khaliel FH, Gustafsson F, Boschi S, Loforte A, Ajello S, Scandroglio AM, Tučanová Z, Netuka I, Schlöglhofer T, Zimpfer D, Zijderhand CF, Caliskan K, Dogan G, Schmitto JD, Maier S, Schibilsky D, Jawad K, Saeed D, Faerber G, Morshuis M, Hanuna M, Müller CS, Mulzer J, Kempfert J, Falk V, Potapov EV. A multicenter evaluation of external outflow graft obstruction with a fully magnetically levitated left ventricular assist device. J Thorac Cardiovasc Surg 2024; 167:1322-1330.e6. [PMID: 36562497 DOI: 10.1016/j.jtcvs.2022.09.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 09/18/2022] [Accepted: 09/26/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND The HeartMate 3 (HM 3; Abbott) left ventricular assist device (LVAD) has improved hemocompatibility-related adverse outcomes. In sporadic cases, external compression of the outflow graft causing obstruction (eOGO) can result from substance accumulation between the outflow graft and its bend relief. We sought to evaluate the prevalence, course, and clinical implications of eOGO in an international study. METHODS A multicenter retrospective analysis of HM 3 LVADs implanted between November 2014 and April 2021 (n = 2108) was conducted across 17 cardiac centers in 8 countries. We defined eOGO as obstruction >25% in the cross-sectional area in imaging (percutaneous angiography, computed tomography, or intravascular ultrasound). The prevalence and annual incidence were calculated. Serious adverse events and outcomes (death, transplantation, or device exchange) were analyzed for eOGO cases. RESULTS Of 2108 patients, 62 were diagnosed with eOGO at a median LVAD support duration of 953 (interquartile range, 600-1267) days. The prevalence of eOGO was 3.0% and the incidence at 1, 2, 3, 4, and 5 years of support was 0.6%, 2.8%, 4.0%, 5.2%, and 9.1%, respectively. Of 62 patients, 9 were observed, 27 underwent surgical revision, 15 underwent percutaneous stent implantation, 8 received a heart transplant, and 2 died before intervention. One patient underwent surgical revision and later stent implantation. The mortality with therapeutic intervention was 9/53 (17.0%). CONCLUSIONS Although uncommon, HM 3 LVAD-supported patients might develop eOGO with an increasing incidence after 1 year of support. Although engineering efforts to reduce this complication are under way, clinicians must maintain a focus on early detection and remain vigilant.
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Affiliation(s)
- Leonhard Wert
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.
| | - Garrick C Stewart
- Division of Cardiovascular Medicine, Center for Advanced Heart Disease, Brigham and Women's Hospital, Boston, Mass
| | - Mandeep R Mehra
- Division of Cardiovascular Medicine, Center for Advanced Heart Disease, Brigham and Women's Hospital, Boston, Mass
| | - Assi Milwidsky
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Ulrich P Jorde
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Daniel J Goldstein
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Craig H Selzman
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Josef Stehlik
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Faisal D Alshamdin
- King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Feras H Khaliel
- King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Silvia Boschi
- Department of Cardiac Surgery, IRCCS Bologna, S. Orsola University Hospital, Bologna, Italy
| | - Antonio Loforte
- Department of Cardiac Surgery, IRCCS Bologna, S. Orsola University Hospital, Bologna, Italy
| | - Silvia Ajello
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute and Vita-Salute San Raffaele University, Milan, Italy
| | - Anna M Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute and Vita-Salute San Raffaele University, Milan, Italy
| | - Zuzana Tučanová
- Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ivan Netuka
- Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Thomas Schlöglhofer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Casper F Zijderhand
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Kadir Caliskan
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Günes Dogan
- Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jan D Schmitto
- Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Sven Maier
- Department of Cardiovascular Surgery, Heart Center University Freiburg-Bad Krozingen, Freiburg, Germany; Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - David Schibilsky
- Department of Cardiovascular Surgery, Heart Center University Freiburg-Bad Krozingen, Freiburg, Germany; Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Khalil Jawad
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
| | - Diyar Saeed
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
| | - Gloria Faerber
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University Jena, Jena, Germany
| | - Michiel Morshuis
- Department of Thoracic and Cardiovascular Surgery, Heart and Diabetes Centre NRW, Ruhr-University of Bochum, Bad Oeynhausen, Germany
| | - Maja Hanuna
- Department of Cardiac Surgery, Ludwig Maximilian University of Munich, Munich, Germany
| | - Christoph S Müller
- Department of Cardiac Surgery, Ludwig Maximilian University of Munich, Munich, Germany
| | - Johanna Mulzer
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Jörg Kempfert
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany; Department of Cardiothoracic Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Department of Health Sciences and Technology, ETH Zürich, Zurich, Switzerland
| | - Evgenij V Potapov
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
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5
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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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6
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Zochios V, Shelley B, Antonini MV, Chawla S, Sato R, Dugar S, Valchanov K, Roscoe A, Scott J, Bangash MN, Akhtar W, Rosenberg A, Dimarakis I, Khorsandi M, Yusuff H. Mechanisms of Acute Right Ventricular Injury in Cardiothoracic Surgical and Critical Care Settings: Part 1. J Cardiothorac Vasc Anesth 2023; 37:2073-2086. [PMID: 37393133 DOI: 10.1053/j.jvca.2023.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 05/21/2023] [Accepted: 06/07/2023] [Indexed: 07/03/2023]
Affiliation(s)
- Vasileios Zochios
- Department of Cardiothoracic Critical Care Medicine and ECMO Unit, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom.
| | - Benjamin Shelley
- Department of Cardiothoracic Anesthesia and Intensive Care, Golden Jubilee National Hospital, Clydebank, United Kingdom; Anesthesia, Perioperative Medicine and Critical Care research group, University of Glasgow, Glasgow, United Kingdom
| | - Marta Velia Antonini
- Anesthesia and Intensive Care Unit, Bufalini Hospital, AUSL della Romagna, Cesena, Italy; Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Modena, Italy
| | - Sanchit Chawla
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Ryota Sato
- Division of Critical Care Medicine, Department of Medicine, The Queen's Medical Center, Honolulu, HI
| | - Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH; Cleveland Clinic Lerner College of Medicine, Case Western University Reserve University, Cleveland, OH
| | - Kamen Valchanov
- Department of Anesthesia and Perioperative Medicine, Singapore General Hospital, Singapore
| | - Andrew Roscoe
- Department of Anesthesia and Perioperative Medicine, Singapore General Hospital, Singapore; Department of Anesthesiology, Singapore General Hospital, National Heart Center, Singapore
| | - Jeffrey Scott
- Jackson Health System, Miami Transplant Institute, Miami, FL
| | - Mansoor N Bangash
- Liver Intensive Care Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom; Birmingham Liver Failure Research Group, Institute of Inflammation and Ageing, College of Medical and Dental sciences, University of Birmingham, Birmingham, United Kingdom; Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, College of Medical and Dental sciences, University of Birmingham, Birmingham, United Kingdom
| | - Waqas Akhtar
- Royal Brompton and Harefield Hospitals, Part of Guys and St. Thomas's National Health System Foundation Trust, London, United Kingdom
| | - Alex Rosenberg
- Royal Brompton and Harefield Hospitals, Part of Guys and St. Thomas's National Health System Foundation Trust, London, United Kingdom
| | - Ioannis Dimarakis
- Division of Cardiothoracic Surgery, University of Washington Medical Center, Seattle, WA
| | - Maziar Khorsandi
- Division of Cardiothoracic Surgery, University of Washington Medical Center, Seattle, WA
| | - Hakeem Yusuff
- Department of Cardiothoracic Critical Care Medicine and ECMO Unit, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; Department of Respiratory Sciences, University of Leicester, Leicester, United Kingdom
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7
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Hoermandinger C, Riedler N, Stein J, Stawowy P, Potapov E, Schoenrath F, Just IA. Acute Outflow Graft Occlusion-A Novel Predictable Complication of Lysis Therapy for the Treatment of Left Ventricular Assist Device Intra-Pump Thrombosis. ASAIO J 2023; 69:827-834. [PMID: 37146602 DOI: 10.1097/mat.0000000000001971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023] Open
Abstract
Lysis therapy is an established treatment option for intra-pump thrombosis of left ventricular assist devices (LVADs). In clinical routine, we observed repeated cases of acute outflow graft occlusions (OGO) associated with lysis therapy with need for urgent intervention. The aim of this investigation was to gain understanding of this observation. We screened data of 962 HeartWare ventricular assist device (HVAD) patients. One hundred twenty (13.8%) had intra-pump thromboses; 58 were treated with recombinant tissue-type plasminogen activator (rtPA). Mean age was 53.0 ± 11.1 years; 84.9% were male. In 13 (24.5%) patients, OGO occurred following rtPA-lysis. These patients showed an increase in left ventricular function (18.45% ± 12.62% to 27.73% ± 10.57%; p = 0.056), more frequent 1:1 aortic valve opening (OGO+: +36.4%; OGO-: +7.4%; p = 0.026), a decrease in LVAD pulsatility within 12 months prior intra-pump thrombosis (OGO+: -0.8 L/min [interquartile range {IQR}, -1.4 to -0.4 L/min]; OGO-: -0.3 L/min [IQR, -0.9 to 0.1 L/min]; p = 0.038) and lower HVAD flows at admission (OGO+: 6.7 L/min [IQR, 6.1-7.4 L/min]; OGO-: 8.3 L/min [IQR, 6.9-9.3 L/min]; p = 0.013), indicating a subclinical OGO prior intra-pump thrombosis. There were no differences in implantation techniques, blood parameters, and lysis strategy. Subclinical OGO represented a major risk factor for acute OGO following rtPA lysis therapy. We here propose an algorithm for risk stratification and dealing with patients presenting this first-described complication. Further research is required to confirm our results and decipher the underlying pathomechanism. http://links.lww.com/ASAIO/B97.
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Affiliation(s)
- Christoph Hoermandinger
- From the Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Nadine Riedler
- From the Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Julia Stein
- From the Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Philipp Stawowy
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- Department of Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Evgenij Potapov
- From the Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Felix Schoenrath
- From the Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- Department of Cardiothoracic Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; and Translational Cardiovascular Technologies, Department of Health Sciences, ETH Zürich, Zürich, Switzerland
| | - Isabell A Just
- From the Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
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8
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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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9
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Dimitrov K, Kaider A, Granegger M, Gross C, Angleitner P, Wiedemann D, Riebandt J, Schaefer AK, Schlöglhofer T, Laufer G, Zimpfer D. The effect of occlusive polytetrafluoroethylene outflow graft protectors in left ventricular assist device recipients. J Heart Lung Transplant 2022; 41:1850-1857. [PMID: 36137868 DOI: 10.1016/j.healun.2022.07.010] [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: 01/25/2022] [Revised: 06/20/2022] [Accepted: 07/13/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The use of polytetrafluoroethylene (PTFE) material as a protective cover for left ventricular assist device (LVAD) outflow grafts (OG) is a common practice. However, it has descriptively been linked to the development of blood flow obstruction (BFO). METHODS Patient data from 194 consecutive HVAD (Medtronic Inc; Medtronic, Minneapolis, MN) recipients implanted between March 2006 and January 2021 were retrospectively analyzed. PTFE covers were used in 102 patients. Study outcomes included the incidence of BFO and survival on LVAD support. RESULTS Thirty-seven patients (19.1%) developed BFO during the study period. On a multivariable Cox regression analysis, PTFE use was an independent predictor for the development of BFO (HR 2.15, 95% CI 1.03-4.48, p = .04). BFO comprised of 2 types of device malfunction: eleven patients (5.7%) developed outflow graft stenosis (OGS), and 31 patients (16.0%) developed pump thrombosis (PT). There was a significantly higher cumulative incidence of OGS in patients with PTFE cover than in those without (Gray's test, p =.03). However, the observed higher cumulative incidence of PT in PTFE patients was non-significant (Gray's test, p =.06). In a multivariable Cox regression model, the effect of PTFE use on survival was non-significant (HR 0.95, 95% CI 0.60-1.48, p =.81), while the development of BFO was independently associated with increased mortality (HR 3.43, 95% CI 1.94-6.06, p < .0001). CONCLUSIONS The use of PTFE OG cover in LVAD patients is associated with an increased cumulative probability of development of BFO, the latter adversely impacting survival and is therefore, harmful.
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Affiliation(s)
- Kamen Dimitrov
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Alexandra Kaider
- Section for Clinical Biometrics, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Marcus Granegger
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Christoph Gross
- Ludwig-Boltzmann-Institute for Cardiovascular Research, Vienna, Austria; Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Philipp Angleitner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Dominik Wiedemann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Julia Riebandt
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Thomas Schlöglhofer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria; Ludwig-Boltzmann-Institute for Cardiovascular Research, Vienna, Austria; Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Günther Laufer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria.
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10
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Velangi PS, Agdamag AC, Nijjar PS, Pogatchnik B, Nijjar PS. Update on CT Imaging of Left Ventricular Assist Devices and Associated Complications. CURRENT CARDIOVASCULAR IMAGING REPORTS 2022. [DOI: 10.1007/s12410-022-09570-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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11
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Numan L, Moazeni M, Oerlemans MI, Aarts E, Van Der Kaaij NP, Asselbergs FW, Van Laake LW. Data-driven monitoring in patients on left ventricular assist device support. Expert Rev Med Devices 2022; 19:677-685. [DOI: 10.1080/17434440.2022.2132147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Lieke Numan
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
| | - Mehran Moazeni
- Department of Methodology and Statistics, Utrecht University, Heidelberglaan 8, 3584 CS, Utrecht, the Netherlands
| | - Marish I.F.J. Oerlemans
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
| | - Emmeke Aarts
- Department of Methodology and Statistics, Utrecht University, Heidelberglaan 8, 3584 CS, Utrecht, the Netherlands
| | - Niels P. Van Der Kaaij
- Department of Cardiothoracic Surgery, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Folkert W. Asselbergs
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
- Institute of Cardiovascular Science, Faculty of Population Health Sciences, University College London, Gower Street, WC1E 6BT, London, UK
- Health Data Research UK and Institute of Health Informatics, University College London, Gower Street, WC1E 6BT, London, UK
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centre, University of Amsterdam, the Netherlands
| | - Linda W. Van Laake
- Department of Cardiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
- Institute of Health Informatics, Faculty of Population Health Sciences, University College London, Gower Street WC1E 6BT, London, UK
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12
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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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13
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Joury A, Patel RAG, Wever-Pinzon J, Eiswirth C, Desai S, Bansal A, Krim SR. Cerebral protection during percutaneous intervention for left ventricular assist device outflow graft obstruction. Catheter Cardiovasc Interv 2022; 100:266-273. [PMID: 35612519 DOI: 10.1002/ccd.30241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 05/02/2022] [Accepted: 05/14/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Left ventricular assist devices (LVAD) outflow graft obstruction is an uncommon complication but carries significant morbidity and mortality. Here we provide a case series of patients with LVAD intrinsic outflow graft obstruction who are deemed to be a high surgical risk for pump exchange and, therefore, underwent percutaneous intervention with the concomitant use of neuroprotective device-Sentinel cerebral protection system (CPS) (Boston Scientific) to prevent embolic stroke. METHODS We retrospectively analyzed patients who underwent LVAD placement in our institution and developed LVAD outflow graft obstruction. The diagnosis of LVAD outflow graft obstruction was confirmed by utilizing various cardiac imaging modalities such as echocardiography and/or computed tomography angiography. All patients were treated with percutaneous intervention and a catheter-based CPS. RESULTS From a total of 501 LVAD implants in our institute, 6 (1.2%) patients with LVAD outflow graft obstruction who underwent percutaneous treatment were included; 4 patients with HeartMate-III LVAD, 1 patient with HeartMate-II LVAD, and 1 patient with HeartWare (HVAD). The median age of patients was 56.5 years at the time of LVAD implantation. The median time from the LVAD implantation to the episode of LVAD outflow obstruction was 1343 days. Utilization of Sentinel CPS resulted in the capture and removal of thrombus/debris in all patients. CONCLUSIONS Percutaneous intervention of LVAD outflow graft obstruction is less invasive than surgical pump exchange and an acceptable alternative in properly selected patients. In our experience, utilization of a catheter-based CPS can help in reducing the incidence of periprocedural embolic events.
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Affiliation(s)
- Abdulaziz Joury
- John Ochsner Heart and Vascular Institute, Ochsner Medical Center, New Orleans, Louisiana, USA.,King Salman Heart Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Rajan A G Patel
- John Ochsner Heart and Vascular Institute, Ochsner Medical Center, New Orleans, Louisiana, USA.,The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, Louisiana, USA.,Interventional Cardiology Section, Ochsner Clinic Foundation, New Orleans, Louisiana, USA
| | - James Wever-Pinzon
- John Ochsner Heart and Vascular Institute, Ochsner Medical Center, New Orleans, Louisiana, USA.,Section of Cardiomyopathy & Heart Transplantation, Ochsner Clinic Foundation, John Ochsner Heart and Vascular Institute, New Orleans, Louisiana, USA
| | - Clement Eiswirth
- John Ochsner Heart and Vascular Institute, Ochsner Medical Center, New Orleans, Louisiana, USA.,Section of Cardiomyopathy & Heart Transplantation, Ochsner Clinic Foundation, John Ochsner Heart and Vascular Institute, New Orleans, Louisiana, USA
| | - Sapna Desai
- John Ochsner Heart and Vascular Institute, Ochsner Medical Center, New Orleans, Louisiana, USA.,Section of Cardiomyopathy & Heart Transplantation, Ochsner Clinic Foundation, John Ochsner Heart and Vascular Institute, New Orleans, Louisiana, USA
| | - Aditya Bansal
- John Ochsner Heart and Vascular Institute, Ochsner Medical Center, New Orleans, Louisiana, USA.,The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, Louisiana, USA.,Department of Surgery, Section of Cardiothoracic Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana, USA
| | - Selim R Krim
- John Ochsner Heart and Vascular Institute, Ochsner Medical Center, New Orleans, Louisiana, USA.,The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, Louisiana, USA.,Section of Cardiomyopathy & Heart Transplantation, Ochsner Clinic Foundation, John Ochsner Heart and Vascular Institute, New Orleans, Louisiana, USA
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14
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Stio RE, Comisso M, Paolucci L, Coletta S, Cesario V, Gioia M, Nazzaro MS, Saitto G, Contento C, D’Avino E, De Felice F, Gabrielli D, Musumeci F. A Redo Percutaneous Emergency Intervention of Left Ventricular Assist Device Graft Occlusion. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19105976. [PMID: 35627512 PMCID: PMC9140931 DOI: 10.3390/ijerph19105976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/11/2022] [Accepted: 05/12/2022] [Indexed: 12/10/2022]
Abstract
In patients with advanced heart failure (HF), left ventricular assist devices (LVADs) have demonstrated to be effective in improving the quality of life and reducing further hospitalizations. Although uncommon, LVAD outflow graft obstruction (OGO) is a potentially life-threatening complication and percutaneous treatment has been proposed as a standard intervention strategy in such cases. We report the case of a 69 year old man admitted due to LVAD failure causing unstable HF. Past medical history included percutaneous intervention on the outflow graft with stent implantation one year before. The patient was under chronic treatment with vitamin K antagonists (VKA). Emergent percutaneous angiography was performed, showing recurrent OGO due to thrombosis located at a kinking site, distally to the previously treated segment. Using distal anchoring technique, a balloon-expandable 10 × 79 mm endoprosthesis (GORE® Viabahn® VBX) was effectively positioned and post-dilated. Final angiography confirmed the patency of the stent implanted one-year before. Despite the procedure succeeding in restoring LVAD function, the patient died due to septic shock ten days after. Our case suggests that recurrent OGO can be effectively treated with percutaneous redo and that long-term stent patency can be achieved with a standard antithrombotic treatment, despite further thrombotic events in other segments of the graft are still possible (especially at the kinking site). Moreover, other noncardiac conditions as infective complications, can dramatically impact the clinical course and lead to unfavorable outcomes.
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Affiliation(s)
- Rocco Edoardo Stio
- Interventional Cardiology Unit, Department of Heart and Vessels, Division of Interventional Cardiology, San Camillo-Forlanini Hospital, 00152 Rome, Italy; (L.P.); (S.C.); (V.C.); (M.G.); (M.S.N.); (F.D.F.); (D.G.)
- Correspondence: ; Tel.: +39-065-870-3323; Fax: +39-065-870-4722
| | - Marina Comisso
- Department of Heart and Vessels, Cardiac Surgery and Heart Transplantation Center, San Camillo-Forlanini Hospital, 00152 Rome, Italy; (M.C.); (G.S.); (F.M.)
| | - Luca Paolucci
- Interventional Cardiology Unit, Department of Heart and Vessels, Division of Interventional Cardiology, San Camillo-Forlanini Hospital, 00152 Rome, Italy; (L.P.); (S.C.); (V.C.); (M.G.); (M.S.N.); (F.D.F.); (D.G.)
| | - Silvio Coletta
- Interventional Cardiology Unit, Department of Heart and Vessels, Division of Interventional Cardiology, San Camillo-Forlanini Hospital, 00152 Rome, Italy; (L.P.); (S.C.); (V.C.); (M.G.); (M.S.N.); (F.D.F.); (D.G.)
| | - Vincenzo Cesario
- Interventional Cardiology Unit, Department of Heart and Vessels, Division of Interventional Cardiology, San Camillo-Forlanini Hospital, 00152 Rome, Italy; (L.P.); (S.C.); (V.C.); (M.G.); (M.S.N.); (F.D.F.); (D.G.)
| | - Michele Gioia
- Interventional Cardiology Unit, Department of Heart and Vessels, Division of Interventional Cardiology, San Camillo-Forlanini Hospital, 00152 Rome, Italy; (L.P.); (S.C.); (V.C.); (M.G.); (M.S.N.); (F.D.F.); (D.G.)
| | - Marco Stefano Nazzaro
- Interventional Cardiology Unit, Department of Heart and Vessels, Division of Interventional Cardiology, San Camillo-Forlanini Hospital, 00152 Rome, Italy; (L.P.); (S.C.); (V.C.); (M.G.); (M.S.N.); (F.D.F.); (D.G.)
| | - Guglielmo Saitto
- Department of Heart and Vessels, Cardiac Surgery and Heart Transplantation Center, San Camillo-Forlanini Hospital, 00152 Rome, Italy; (M.C.); (G.S.); (F.M.)
| | - Carlo Contento
- Department of Cardiovascular Anaesthesia, San Camillo-Forlanini Hospital, 00152 Rome, Italy; (C.C.); (E.D.)
| | - Emilio D’Avino
- Department of Cardiovascular Anaesthesia, San Camillo-Forlanini Hospital, 00152 Rome, Italy; (C.C.); (E.D.)
| | - Francesco De Felice
- Interventional Cardiology Unit, Department of Heart and Vessels, Division of Interventional Cardiology, San Camillo-Forlanini Hospital, 00152 Rome, Italy; (L.P.); (S.C.); (V.C.); (M.G.); (M.S.N.); (F.D.F.); (D.G.)
| | - Domenico Gabrielli
- Interventional Cardiology Unit, Department of Heart and Vessels, Division of Interventional Cardiology, San Camillo-Forlanini Hospital, 00152 Rome, Italy; (L.P.); (S.C.); (V.C.); (M.G.); (M.S.N.); (F.D.F.); (D.G.)
| | - Francesco Musumeci
- Department of Heart and Vessels, Cardiac Surgery and Heart Transplantation Center, San Camillo-Forlanini Hospital, 00152 Rome, Italy; (M.C.); (G.S.); (F.M.)
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15
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Agrawal A, Alexy T, Kamioka N, Shafi T, Stowe J, Morris AA, Vega JD, Babaliaros V, Burke MA. Outflow graft obstruction after left ventricular assist device implantation: a retrospective, single-centre case series. ESC Heart Fail 2021; 8:2349-2353. [PMID: 33787080 PMCID: PMC8120379 DOI: 10.1002/ehf2.13333] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 02/24/2021] [Accepted: 03/12/2021] [Indexed: 11/22/2022] Open
Abstract
Aims Outflow graft obstruction is a poorly described complication following left ventricular assist device (LVAD) surgery. We sought to define the incidence of LVAD outflow graft obstruction and assess clinical outcomes with a percutaneous treatment strategy. Methods and results From January 2012 to October 2020, 322 patients with LVAD were managed at our institution. Patients with LVAD outflow graft obstruction were identified by cardiac computed tomography with angiography and invasive haemodynamic assessment and were subsequently treated with percutaneous intervention. Poisson regression was used to analyse time‐dependent differences in the incidence of LVAD outflow graft obstruction. Kaplan–Meier analysis was used to estimate survival. Twenty patients (6.2%) developed haemodynamically significant LVAD outflow graft obstruction at a rate of 0.03 events per patient‐year. Outflow graft obstruction presented a median of 33 (26–49) months after surgery. Patients presented with low estimated LVAD pump flow (95%), heart failure (90%), or both (85%), and 59% developed cardiogenic shock prior to intervention. The most common aetiology identified by cardiac computed tomography with angiography was external compression of the outflow graft (78%). On presentation, the median peak gradient in the outflow graft was 78 (64–100) mmHg. Outflow graft stenting was 100% successful with no in‐hospital mortality, and it reduced the peak outflow graft gradient to 10 (2–17) mmHg (P < 0.001). Outflow graft stenting was durable with two patients (10%) requiring a repeat procedure over a median follow‐up of 13 (7–20) months and did not impact survival. Conclusions Left ventricular assist device outflow graft obstruction is a relatively common and underappreciated cause of recurrent heart failure and LVAD dysfunction. Outflow graft stenting can be achieved with low morbidity and provides a long‐term solution to this complication.
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Affiliation(s)
- Akanksha Agrawal
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, 101 Woodruff Circle, Suite 322, Atlanta, GA, 30322, USA
| | - Tamas Alexy
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, 101 Woodruff Circle, Suite 322, Atlanta, GA, 30322, USA
| | - Norihiko Kamioka
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, 101 Woodruff Circle, Suite 322, Atlanta, GA, 30322, USA
| | - Taimur Shafi
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, 101 Woodruff Circle, Suite 322, Atlanta, GA, 30322, USA
| | - Judson Stowe
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, 101 Woodruff Circle, Suite 322, Atlanta, GA, 30322, USA
| | - Alanna A Morris
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, 101 Woodruff Circle, Suite 322, Atlanta, GA, 30322, USA
| | - J David Vega
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Vasilis Babaliaros
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, 101 Woodruff Circle, Suite 322, Atlanta, GA, 30322, USA
| | - Michael A Burke
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, 101 Woodruff Circle, Suite 322, Atlanta, GA, 30322, USA
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