Utilization of Cardiac Computed Tomography Angiography for the Diagnosis of Left Ventricular Assist Device Thrombosis
2012; Lippincott Williams & Wilkins; Volume: 5; Issue: 2 Linguagem: Inglês
10.1161/circheartfailure.111.966119
ISSN1941-3297
AutoresJoseph D. Mishkin, Jonathan Enriquez, Dan M. Meyer, Brian Bethea, Jennifer T. Thibodeau, Parag C. Patel, David W. Markham, Pradeep P.A. Mammen, Mariella Vélez-Martínez, Mark H. Drazner,
Tópico(s)Cardiac Arrest and Resuscitation
ResumoHomeCirculation: Heart FailureVol. 5, No. 2Utilization of Cardiac Computed Tomography Angiography for the Diagnosis of Left Ventricular Assist Device Thrombosis Free AccessBrief ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessBrief ReportPDF/EPUBUtilization of Cardiac Computed Tomography Angiography for the Diagnosis of Left Ventricular Assist Device Thrombosis Joseph D. Mishkin, MD, Jonathan R. Enriquez, MD, Dan M. Meyer, MD, Brian T. Bethea, MD, Jennifer T. Thibodeau, MD, Parag C. Patel, MD, David W. Markham, MD, MSc, Pradeep P.A. Mammen, MD, Mariella Velez-Martinez, MD and Mark H. Drazner, MD, MSc Joseph D. MishkinJoseph D. Mishkin From the Division of Cardiology (J.D.M., J.R.E., J.T.T., P.C.P., D.W.M., P.P.A.M., M.V.-M., M.H.D.) and the Division of Cardiothoracic Surgery (D.M.M., B.T.B.), University of Texas–Southwestern Medical Center, Dallas, TX. , Jonathan R. EnriquezJonathan R. Enriquez From the Division of Cardiology (J.D.M., J.R.E., J.T.T., P.C.P., D.W.M., P.P.A.M., M.V.-M., M.H.D.) and the Division of Cardiothoracic Surgery (D.M.M., B.T.B.), University of Texas–Southwestern Medical Center, Dallas, TX. , Dan M. MeyerDan M. Meyer From the Division of Cardiology (J.D.M., J.R.E., J.T.T., P.C.P., D.W.M., P.P.A.M., M.V.-M., M.H.D.) and the Division of Cardiothoracic Surgery (D.M.M., B.T.B.), University of Texas–Southwestern Medical Center, Dallas, TX. , Brian T. BetheaBrian T. Bethea From the Division of Cardiology (J.D.M., J.R.E., J.T.T., P.C.P., D.W.M., P.P.A.M., M.V.-M., M.H.D.) and the Division of Cardiothoracic Surgery (D.M.M., B.T.B.), University of Texas–Southwestern Medical Center, Dallas, TX. , Jennifer T. ThibodeauJennifer T. Thibodeau From the Division of Cardiology (J.D.M., J.R.E., J.T.T., P.C.P., D.W.M., P.P.A.M., M.V.-M., M.H.D.) and the Division of Cardiothoracic Surgery (D.M.M., B.T.B.), University of Texas–Southwestern Medical Center, Dallas, TX. , Parag C. PatelParag C. Patel From the Division of Cardiology (J.D.M., J.R.E., J.T.T., P.C.P., D.W.M., P.P.A.M., M.V.-M., M.H.D.) and the Division of Cardiothoracic Surgery (D.M.M., B.T.B.), University of Texas–Southwestern Medical Center, Dallas, TX. , David W. MarkhamDavid W. Markham From the Division of Cardiology (J.D.M., J.R.E., J.T.T., P.C.P., D.W.M., P.P.A.M., M.V.-M., M.H.D.) and the Division of Cardiothoracic Surgery (D.M.M., B.T.B.), University of Texas–Southwestern Medical Center, Dallas, TX. , Pradeep P.A. MammenPradeep P.A. Mammen From the Division of Cardiology (J.D.M., J.R.E., J.T.T., P.C.P., D.W.M., P.P.A.M., M.V.-M., M.H.D.) and the Division of Cardiothoracic Surgery (D.M.M., B.T.B.), University of Texas–Southwestern Medical Center, Dallas, TX. , Mariella Velez-MartinezMariella Velez-Martinez From the Division of Cardiology (J.D.M., J.R.E., J.T.T., P.C.P., D.W.M., P.P.A.M., M.V.-M., M.H.D.) and the Division of Cardiothoracic Surgery (D.M.M., B.T.B.), University of Texas–Southwestern Medical Center, Dallas, TX. and Mark H. DraznerMark H. Drazner From the Division of Cardiology (J.D.M., J.R.E., J.T.T., P.C.P., D.W.M., P.P.A.M., M.V.-M., M.H.D.) and the Division of Cardiothoracic Surgery (D.M.M., B.T.B.), University of Texas–Southwestern Medical Center, Dallas, TX. Originally published1 Mar 2012https://doi.org/10.1161/CIRCHEARTFAILURE.111.966119Circulation: Heart Failure. 2012;5:e27–e29The use of left ventricular assist devices (LVADs) in the management of advanced heart failure has grown substantially in recent years, with implantation of these devices increasing 10-fold since the approval of a continuous-flow device for destination therapy in January 2010. With the significant increase in use of this technology comes the potential for an increased incidence of complications associated with these devices. One such complication that can be fatal if not urgently recognized is device thrombosis, which has been reported to occur in approximately 1% of patients receiving the HeartMate II LVAD.1 Cardiologists, radiologists, and other health care professionals must become increasingly more adept at diagnosing this complication to allow rapid institution of appropriate therapy. We report a case of a patient presenting with LVAD thrombosis diagnosed with cardiac computed tomography angiography (CTA).Patient PresentationA 45-year-old white man with a history of a nonischemic cardiomyopathy presented with refractory cardiogenic shock requiring implantation of a continuous-flow LVAD because the patient's body mass index precluded cardiac transplantation. Two months after implant, the patient presented with "low flow" alarms and hemolysis (elevated lactate dehydrogenase and undetectable haptoglobin) despite therapeutic anticoagulation. An echocardiogram showed the aortic valve opening with every cardiac cycle and low flow velocity through the inflow cannula, suggesting inadequate unloading of the left ventricle. A CTA of the chest was obtained by means of helical scanning with 2-mm-thickness retracted images during the arterial phase of intravenous contrast administration. Additional delayed images were also obtained. The CTA demonstrated complete thrombosis of the outflow graft with contrast being ejected directly from the left ventricle into the aorta (Figures 1 and 2). Contrast is subsequently seen refluxing into the totally occluded outflow graft (Figure 3). The patient exhibited adequate native cardiac function as assessed by invasive hemodynamic monitoring with a cardiac index of 3.6 L/min per m2 and normal filling pressures. Because of massive thrombosis and an overheating system controller, the pump was disconnected from its power source to prevent thromboembolic events. Explantation of the LVAD was not performed to avoid precipitating hemodynamic instability. The patient remains stable in the outpatient setting, with contingency plans for orthotopic heart transplantation if required.Download figureDownload PowerPointFigure 1. Complete thrombosis of the outflow graft.Download figureDownload PowerPointFigure 2. Axial image of contrast being ejected into the aorta directly from the left ventricle.Download figureDownload PowerPointFigure 3. Contrast refluxing into the occluded outflow graft.DiscussionThis case illustrates the use of cardiac CTA for diagnosis of LVAD thrombosis. No standard algorithm exists for the timely and accurate diagnosis of this clinical entity. Other potentially useful diagnostic modalities have been previously described, including the use of blood and urine tests to evaluate for evidence of hemolysis, echocardiography,2 and analysis of device data (ie, flow, power, and speed rates). To our knowledge, the successful diagnosis of LVAD thrombosis using cardiac CTA has not been well described. Although cardiac CTA has been used to identify cannula malposition,3 only 1 prior case series documented outflow graft thrombosis with the use of cardiac CTA.4 Further research and consideration are needed to determine the optimal algorithm to diagnose this potentially life-threatening LVAD complication.DisclosuresDr Drazner participated in a clinical registry (ESP) for Thoratec Corporation; Dr Markham received grant support from Thoratec Corporation.FootnotesCorrespondence to Joseph D. Mishkin, MD, Division of Cardiology, University of Texas-Southwestern Medical Center at Dallas, 5323 Harry Hines Blvd, Dallas, TX 75390-9047. E-mail joseph.[email protected]eduReferences1. Pagani FD, Miller LW, Russell SD, Aaronson KD, John R, Boyle AJ, Conte JV, Bogaev RC, MacGillivray TE, Naka Y, Mancini D, Massey HT, Chen L, Klodell CT, Aranda JM, Moazami N, Ewald GA, Farrar DJ, Frazier OH. Extended mechanical circulatory support with a continuous-flow rotary left ventricular assist device. J Am Coll Cardiol. 2009; 54:312–321.CrossrefMedlineGoogle Scholar2. Paluszkiewicz L, Gursoy D, Spiliopoulos S, Dogan G, Daliakopoulos S, Tenderich M, Körfer R, Tenderich G. HeartMate II ventricular assist device thrombosis: an echocardiographic approach to diagnosis: can Doppler evaluation of flow be useful?J Am Soc Echocardiogr. 2011; 24:350 e351–e354.CrossrefGoogle Scholar3. Acharya D, Singh S, Tallaj JA, Holman WL, George JF, Kirklin JK, Pamboukian SV. Use of gated cardiac computed tomography angiography in the assessment of left ventricular assist device dysfunction. ASAIO J. 2011; 57:32–37.CrossrefMedlineGoogle Scholar4. Raman SV, Sahu A, Merchant AZ, Louis LBT, Firstenberg MS, Sun B. Noninvasive assessment of left ventricular assist devices with cardiovascular computed tomography and impact on management. 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Uriel N, Morrison K, Garan A, Kato T, Yuzefpolskaya M, Latif F, Restaino S, Mancini D, Flannery M, Takayama H, John R, Colombo P, Naka Y and Jorde U (2012) Development of a Novel Echocardiography Ramp Test for Speed Optimization and Diagnosis of Device Thrombosis in Continuous-Flow Left Ventricular Assist Devices, Journal of the American College of Cardiology, 10.1016/j.jacc.2012.07.052, 60:18, (1764-1775), Online publication date: 1-Oct-2012. March 2012Vol 5, Issue 2 Advertisement Article InformationMetrics © 2012 American Heart Association, Inc.https://doi.org/10.1161/CIRCHEARTFAILURE.111.966119PMID: 22438526 Manuscript receivedDecember 13, 2011Manuscript acceptedJanuary 23, 2012Originally publishedMarch 1, 2012 KeywordsLVADimagingthrombusheart assist devicePDF download Advertisement SubjectsCardiovascular SurgeryComputerized Tomography (CT)Heart FailureThrombosis
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