Portal de Periódicos da CAPES

Diagnosis of Left Ventricular Assist Device Outflow Graft Obstruction Using Intravascular Ultrasound

2016; Lippincott Williams & Wilkins; Volume: 9; Issue: 12 Linguagem: Inglês

10.1161/circheartfailure.116.003472

1941-3297

Hellmuth R. Muller Moran, Malek Kass, Amir Ravandi, Shelley Zieroth, Stephen Allan Schaffer, Francisco Córdova, Zlatko Pozeg, Rakesh C. Arora, Rohit K. Singal,

Cardiac Arrest and Resuscitation

HomeCirculation: Heart FailureVol. 9, No. 12Diagnosis of Left Ventricular Assist Device Outflow Graft Obstruction Using Intravascular Ultrasound Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUBDiagnosis of Left Ventricular Assist Device Outflow Graft Obstruction Using Intravascular Ultrasound Hellmuth R. Muller Moran, MD, Malek Kass, MD, FRCPC, Amir Ravandi, MD, PhD, FRCPC, Shelley Zieroth, MD, FRCPC, S. Allan Schaffer, MD, FRCPC, Francisco J. Cordova, MD, Zlatko I. Pozeg, MD, FRCSC, Rakesh C. Arora, MD, PhD, FRCSC and Rohit K. Singal, MD, MSc, FRCSC Hellmuth R. Muller MoranHellmuth R. Muller Moran From the Department of Surgery (H.R.M.M., Z.I.P., R.C.A., R.K.S.) and Department of Medicine (M.K., A.R., S.Z., S.A.S., F.J.C.), Max Rady College of Medicine, University of Manitoba, Canada; and Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada (H.R.M.M., M.K., A.R., S.Z., S.A.S., F.J.C., Z.I.P., R.C.A., R.K.S.). , Malek KassMalek Kass From the Department of Surgery (H.R.M.M., Z.I.P., R.C.A., R.K.S.) and Department of Medicine (M.K., A.R., S.Z., S.A.S., F.J.C.), Max Rady College of Medicine, University of Manitoba, Canada; and Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada (H.R.M.M., M.K., A.R., S.Z., S.A.S., F.J.C., Z.I.P., R.C.A., R.K.S.). , Amir RavandiAmir Ravandi From the Department of Surgery (H.R.M.M., Z.I.P., R.C.A., R.K.S.) and Department of Medicine (M.K., A.R., S.Z., S.A.S., F.J.C.), Max Rady College of Medicine, University of Manitoba, Canada; and Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada (H.R.M.M., M.K., A.R., S.Z., S.A.S., F.J.C., Z.I.P., R.C.A., R.K.S.). , Shelley ZierothShelley Zieroth From the Department of Surgery (H.R.M.M., Z.I.P., R.C.A., R.K.S.) and Department of Medicine (M.K., A.R., S.Z., S.A.S., F.J.C.), Max Rady College of Medicine, University of Manitoba, Canada; and Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada (H.R.M.M., M.K., A.R., S.Z., S.A.S., F.J.C., Z.I.P., R.C.A., R.K.S.). , S. Allan SchafferS. Allan Schaffer From the Department of Surgery (H.R.M.M., Z.I.P., R.C.A., R.K.S.) and Department of Medicine (M.K., A.R., S.Z., S.A.S., F.J.C.), Max Rady College of Medicine, University of Manitoba, Canada; and Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada (H.R.M.M., M.K., A.R., S.Z., S.A.S., F.J.C., Z.I.P., R.C.A., R.K.S.). , Francisco J. CordovaFrancisco J. Cordova From the Department of Surgery (H.R.M.M., Z.I.P., R.C.A., R.K.S.) and Department of Medicine (M.K., A.R., S.Z., S.A.S., F.J.C.), Max Rady College of Medicine, University of Manitoba, Canada; and Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada (H.R.M.M., M.K., A.R., S.Z., S.A.S., F.J.C., Z.I.P., R.C.A., R.K.S.). , Zlatko I. PozegZlatko I. Pozeg From the Department of Surgery (H.R.M.M., Z.I.P., R.C.A., R.K.S.) and Department of Medicine (M.K., A.R., S.Z., S.A.S., F.J.C.), Max Rady College of Medicine, University of Manitoba, Canada; and Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada (H.R.M.M., M.K., A.R., S.Z., S.A.S., F.J.C., Z.I.P., R.C.A., R.K.S.). , Rakesh C. AroraRakesh C. Arora From the Department of Surgery (H.R.M.M., Z.I.P., R.C.A., R.K.S.) and Department of Medicine (M.K., A.R., S.Z., S.A.S., F.J.C.), Max Rady College of Medicine, University of Manitoba, Canada; and Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada (H.R.M.M., M.K., A.R., S.Z., S.A.S., F.J.C., Z.I.P., R.C.A., R.K.S.). and Rohit K. SingalRohit K. Singal From the Department of Surgery (H.R.M.M., Z.I.P., R.C.A., R.K.S.) and Department of Medicine (M.K., A.R., S.Z., S.A.S., F.J.C.), Max Rady College of Medicine, University of Manitoba, Canada; and Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada (H.R.M.M., M.K., A.R., S.Z., S.A.S., F.J.C., Z.I.P., R.C.A., R.K.S.). Originally published18 Nov 2016https://doi.org/10.1161/CIRCHEARTFAILURE.116.003472Circulation: Heart Failure. 2016;9:e003472BackgroundOriginally conceived of as a means for bridging patients to heart transplantation, the encouraging long-term outcomes of left ventricular assist devices (LVADs) have led to their increased use in the treatment of heart failure, even in cases where transplant candidacy or availability is unlikely. Despite the life-saving aspects of LVAD therapy to support the patient with end-stage heart failure, issues of pump obstruction and thrombosis persist, resulting in an increasing need for emergent device exchanges or deaths from thrombosis.1 This forms a diagnostic dilemma for care providers because there are a variety of clinical syndromes that may mimic this feared complication, yet the treatment options for bona fide pump thrombosis are limited. Although algorithms have been proposed to address this problem in a standardized fashion,2 there remains considerable heterogeneity in the diagnosis and management of pump thrombosis between centers. Where outflow graft obstruction is suspected, vascular ultrasound has previously been used intraoperatively to confirm the presence of outflow graft obstruction.3 However, intravascular ultrasound (IVUS) offers the benefit of confirming obstruction before taking the patient to the operating suite for device exchange. We present a case of HeartMate II LVAD (Thoratec Corporation, CA) thrombosis in which IVUS was used in this very manner; the first reported case of its kind.Case ReportA 65-year-old female (62 kg) with a history of nonischemic dilated cardiomyopathy, rate-controlled atrial fibrillation with prior cardioembolic stroke, hypertension, and osteoporosis presented with worsening symptoms of decompensated heart failure. Despite a prolonged listing for transplant, a suitable donor was not identified on account of her size, blood group (type O), and sensitization. Consent was obtained to proceed with elective implantation of a HeartMate II LVAD (INTERMACS—Interagency Registry for Mechanically Assisted Circulatory Support—status 3). This was performed along with tricuspid valve annuloplasty and surgical coaptation of the aortic valve leaflets using a Park stitch.4The postoperative course was complicated by residual right ventricular dysfunction that required a prolonged administration of intravenous inodilators (milirinone and nitric oxide), diuresis with furosemide, and initiation of maintenance therapy with oral sildenafil and furosemide. This strategy was pursued in lieu of mechanically supporting the right ventricle because patients have been known to experience poorer outcomes with biventricular mechanical support. Approximately 2 weeks after implantation, the patient experienced a sudden, yet transient and asymptomatic pump stoppage that resolved spontaneously. This was accompanied by ongoing pulsatility index events that were detectable only on waveform analysis and which resolved after decreasing the pump speed to 8400 rpm. She continued to recover until ≈4 weeks after implantation when her clinical status began to deteriorate with worsening weakness and shortness of breath requiring aggressive diuresis and increases of her VAD parameters. Serum markers were suggestive of hemolysis, and appropriate investigations were performed.2The diagnostic strategy to determine the cause of the LVAD pump difficulties included an echocardiographic ramp study, computed tomography of the chest, and outflow conduit angiography. The ramp study demonstrated incomplete left ventricular decompression with increased LVAD speed to 10 400 rpm and severe right ventricular dysfunction. This raised suspicions for the presence of an outflow graft stenosis, which became further suspected based on computed tomography scans and conduit angiography demonstrating a narrowing near the aortic anastomosis of the outflow graft (Figure 1). To confirm the severity of this potential stenosis and to clarify its hemodynamic significance, the site was further assessed using IVUS and dual-lumen simultaneous pressure measurement.Intravascular access was obtained with ultrasound guidance via the right femoral artery, and the outflow graft was successfully catheterized using an Amplatz 1 guiding catheter (Boston Scientific, MA). Simultaneous pressure measurements across the conduit and aorta, taken using a 6-French Langston dual-lumen catheter (Vascular Solutions, MN), revealed a peak-to-peak pressure gradient of 24 mm Hg and mean pressure gradient of 11 mm Hg (Figure 2). An extra S-port guidewire was placed into the mid-segment of the outflow conduit, and the patient was then heparinized with 3000 U intravenously. IVUS (Atlantis SR pro; Boston Scientific) was then used to accurately examine the severity of the stenosis by engaging the outflow graft with the probe under fluoroscopy and gradually withdrawing it back to the outflow anastomosis with the aorta while imaging. This confirmed an ≈50% stenosis at the aforementioned site in the outflow graft (Figure 3; Movie I in the Data Supplement).Percutaneous treatment of the outflow graft stenosis was considered; however, serum markers of hemolysis were elevated consistent with pump thrombosis. Therefore, consent was obtained to proceed with pump exchange and revision of the outflow graft. An errant anastomotic repair suture found to be causing the outflow graft stenosis was cut and released. Pump exchange was performed with no complications, and a thrombus was visually confirmed in the explanted device (Figure 4). After implantation of a new HeartMate II LVAD, echocardiographic analysis demonstrated a decompressed ventricle with pump speeds of 8200 rpm and resolution of the outflow graft stenosis; there was no appreciable pressure gradient across this site. The patient's postoperative course was generally unremarkable, but prolonged, because she required steady diuresis and physical reconditioning. She was discharged home in stable condition ≈5 weeks after the pump exchange procedure. At most recent postdischarge follow-up clinic visit, the patient was clinically stable now 17 months after her pump exchange procedure.This case is the first description of IVUS characterization of the outflow graft of an actively working LVAD. In cases where LVAD outflow graft obstruction is suspected, IVUS may not only help confirm and characterize the nature and severity of an obstruction but is likely more detailed than other traditional modalities. Because surgical management of pump thrombosis is significantly affected by the presence of an outflow graft obstruction, it is a useful adjunct in cases where diagnosis and severity are uncertain.Download figureDownload PowerPointFigure 1. Narrowing of the outflow graft near the aortic anastomosis site, indicated by white arrows. Visualized using computed tomography (A) and conduit angiography (B).Download figureDownload PowerPointFigure 2. Langston catheter measurements showing a significant pressure gradient from the outflow graft to the aorta. The values in blue correspond to the measured aortic pressure, whereas the values in red correspond to the outflow graft pressure.Download figureDownload PowerPointFigure 3. Intravascular ultrasound (IVUS) image confirming an outflow graft stenosis of ≈50%.Download figureDownload PowerPointFigure 4. A thrombus is visualized in the lumen of the explanted left ventricular assist device (LVAD), indicated by the white arrow. The thrombus is located at the inflow portion of the device, proximal to the pump rotor.DisclosuresDr Arora has received an unrestricted research grant from Pfizer Canada Inc. and honoraria from Mallindkrodt Pharmaceuticals. The other authors report no conflicts.FootnotesThe Data Supplement is available at http://circheartfailure.ahajournals.org/lookup/suppl/doi:10.1161/CIRCHEARTFAILURE.116.003472/-/DC1.Correspondence to Rohit K. Singal, MD, FRCSC, Manitoba Cardiac Sciences Program, St Boniface General Hospital, I.H. Asper Clinical Research Institute, CR 3030-369 Tache Ave, Winnipeg, Manitoba, Canada R2H 2A6. E-mail [email protected]References1. Starling RC, Moazami N, Silvestry SC, Ewald G, Rogers JG, Milano CA, Rame JE, Acker MA, Blackstone EH, Ehrlinger J, Thuita L, Mountis MM, Soltesz EG, Lytle BW, Smedira NG.Unexpected abrupt increase in left ventricular assist device thrombosis.N Engl J Med. 2014; 370:33–40. doi: 10.1056/NEJMoa1313385.CrossrefMedlineGoogle Scholar2. Goldstein DJ, John R, Salerno C, Silvestry S, Moazami N, Horstmanshof D, Adamson R, Boyle A, Zucker M, Rogers J, Russell S, Long J, Pagani F, Jorde U.Algorithm for the diagnosis and management of suspected pump thrombus.J Heart Lung Transplant. 2013; 32:667–670. doi: 10.1016/j.healun.2013.05.002.CrossrefMedlineGoogle Scholar3. Smith ES, Nelson MT, Tang DG.Intraoperative use of vascular ultrasound to localize thrombus in left ventricular assist device exchange.Anesth Analg. 2016; 122:27–30. doi: 10.1213/ANE.0000000000000980.CrossrefMedlineGoogle Scholar4. Park SJ, Liao KK, Segurola R, Madhu KP, Miller LW.Management of aortic insufficiency in patients with left ventricular assist devices: a simple coaptation stitch method (Park's stitch).J Thorac Cardiovasc Surg. 2004; 127:264–266. doi: 10.1016/S0022.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Raza M, Williams N, Barry N and Singh V (2020) Percutaneous treatment of left ventricular assist device outflow graft obstruction, Catheterization and Cardiovascular Interventions, 10.1002/ccd.29190, 97:1, (152-156), Online publication date: 1-Jan-2021. Barac Y, Nevo A, Schroder J, Milano C and Daneshmand M (2020) LVAD Outflow Graft Role in Pump Thrombosis, ASAIO Journal, 10.1097/MAT.0000000000000936, 66:2, (128-131), Online publication date: 1-Feb-2020. Nathan S, Ghotra A, Rajagopal K, Patel C, Kumar S, Patel M, Salas de Armas I, Jumean M, Akay M, Akkanti B, Kar B and Gregoric I (2019) Left Ventricular Assist Device Outflow Graft Obstruction: A Case Series, ASAIO Journal, 10.1097/MAT.0000000000001060, 66:6, (657-662), Online publication date: 1-Jun-2020. Burrell A, Salamonsen R and Murphy D (2018) Complications of mechanical circulatory and respiratory support Mechanical Circulatory and Respiratory Support, 10.1016/B978-0-12-810491-0.00016-3, (495-528), . Tchoukina I, Smallfield M and Shah K (2018) Device Management and Flow Optimization on Left Ventricular Assist Device Support, Critical Care Clinics, 10.1016/j.ccc.2018.03.002, 34:3, (453-463), Online publication date: 1-Jul-2018. December 2016Vol 9, Issue 12 Advertisement Article InformationMetrics © 2016 American Heart Association, Inc.https://doi.org/10.1161/CIRCHEARTFAILURE.116.003472PMID: 27864303 Originally publishedNovember 18, 2016 Keywordsintravascular ultrasoundthrombosisheart transplantationheart failureleft ventricular assist devicePDF download Advertisement SubjectsCardiovascular SurgeryComplicationsHeart FailureTreatmentUltrasound