Left Ventricular Assist Device Outflow Graft Obstruction, Multi-Institutional Treatment with Percutaneous Stenting
Tyler J. Wallen1, Ahmet Kilic2, Alejandro Suarez-Pierre3, Siddharth S. Wayangankar1, David S. Anderson1, Mustafa Ahmed1, Juan Aranda1, Juan Vilaro1, Eric Jeng1, Thomas Beaver1, George Arnaoutakis1.
1The University of Florida, Gainesville, FL, USA, 2Johns Hopkins Hospital, Baltimore, MD, USA, 3Johns Hopkins University, Baltimore, MD, USA.
Objective: To describe experience treating LVAD outflow graft obstruction with percutaneous stenting.
Background: Left ventricular assist device (LVAD) outflow graft obstruction is a challenging clinical problem that can manifest with low LVAD flows, worsening heart failure, and pump thrombosis.
Methods: All patients presented with symptoms of heart failure, elevated pulmonary artery pressures, and low flow alarms. All patients underwent a CT scanning and echocardiography. The outflow graft was accessed via the common femoral artery and aortography was performed. Balloon-expandable covered stents were advanced into the outflow graft. Speeds were reduced with heparinization to an ACT > 250 seconds; the stents were deployed. Intra-vascular ultrasound was used to confirm placement and expansion. The outflow graft then underwent angioplasty.
Results: Median duration of support pre-intervention was 30.4 +/- 5.1 months. Three patients (60%) were in decompensated congestive heart failure, requiring intravenous inotropes and intra-aortic balloon pump support. Catheterization data demonstrated an average right atrial pressure of 16.3 +/- 6.3 mmHg and an average pulmonary artery pressure of 36.3 +/- 6.8 mmHg. The mean number of stents deployed was 2.5. LVAD flows increased significantly in all patients after the procedure with an average increase in flow of 3.1 + 1.4 L/min (Figure 1). All patients were successfully weaned from intravenous inotrope support and discharged.
Conclusions: Left ventricular assist device outflow graft obstruction is a challenging problem that is amenable to percutaneous endovascular treatment with good results. This minimally invasive approach offers an expedited recovery and obviates high risk redo sternotomy in selected patients.
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