Outflow Graft Occlusion of the HeartMate 3 Left Ventricular Assist Device
2017; Lippincott Williams & Wilkins; Volume: 10; Issue: 9 Linguagem: Inglês
10.1161/circheartfailure.117.004275
ISSN1941-3297
AutoresJuan Duero Posada, Yasbanoo Moayedi, Mosaad Alhussein, Marnie Rodger, Juglans Alvarez, Bernd J. Wintersperger, Heather J. Ross, Jagdish Butany, Filio Billia, Vivek Rao,
Tópico(s)Fuel Cells and Related Materials
ResumoHomeCirculation: Heart FailureVol. 10, No. 9Outflow Graft Occlusion of the HeartMate 3 Left Ventricular Assist Device Free AccessCase ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessCase ReportPDF/EPUBOutflow Graft Occlusion of the HeartMate 3 Left Ventricular Assist Device Juan G. Duero Posada, MD, Yasbanoo Moayedi, MD, Mosaad Alhussein, MD, Marnie Rodger, RN, NP, Juglans Alvarez, MD, Bernd J. Wintersperger, MBBS, Heather J. Ross, MD, MSc, Jagdish Butany, MD, Filio Billia, MD, PhD and Vivek Rao, MD, PhD Juan G. Duero PosadaJuan G. Duero Posada From the Department of Medicine (J.G.D.P., Y.M., M.A., H.J.R., F.B.), Division of Cardiology (J.G.D.P., Y.M., M.A., H.J.R., F.B.), Division of Cardiovascular Surgery, Department of Surgery (M.R., J.A., V.R.), Department of Medical Imaging, Peter Munk Cardiac Centre (B.J.W.), Ted Rogers Centre for Heart Research (M.R., H.J.R., F.B., V.R.), and Laboratory Medicine and Pathology (J.B.), Toronto General Hospital, University of Toronto, Canada. , Yasbanoo MoayediYasbanoo Moayedi From the Department of Medicine (J.G.D.P., Y.M., M.A., H.J.R., F.B.), Division of Cardiology (J.G.D.P., Y.M., M.A., H.J.R., F.B.), Division of Cardiovascular Surgery, Department of Surgery (M.R., J.A., V.R.), Department of Medical Imaging, Peter Munk Cardiac Centre (B.J.W.), Ted Rogers Centre for Heart Research (M.R., H.J.R., F.B., V.R.), and Laboratory Medicine and Pathology (J.B.), Toronto General Hospital, University of Toronto, Canada. , Mosaad AlhusseinMosaad Alhussein From the Department of Medicine (J.G.D.P., Y.M., M.A., H.J.R., F.B.), Division of Cardiology (J.G.D.P., Y.M., M.A., H.J.R., F.B.), Division of Cardiovascular Surgery, Department of Surgery (M.R., J.A., V.R.), Department of Medical Imaging, Peter Munk Cardiac Centre (B.J.W.), Ted Rogers Centre for Heart Research (M.R., H.J.R., F.B., V.R.), and Laboratory Medicine and Pathology (J.B.), Toronto General Hospital, University of Toronto, Canada. , Marnie RodgerMarnie Rodger From the Department of Medicine (J.G.D.P., Y.M., M.A., H.J.R., F.B.), Division of Cardiology (J.G.D.P., Y.M., M.A., H.J.R., F.B.), Division of Cardiovascular Surgery, Department of Surgery (M.R., J.A., V.R.), Department of Medical Imaging, Peter Munk Cardiac Centre (B.J.W.), Ted Rogers Centre for Heart Research (M.R., H.J.R., F.B., V.R.), and Laboratory Medicine and Pathology (J.B.), Toronto General Hospital, University of Toronto, Canada. , Juglans AlvarezJuglans Alvarez From the Department of Medicine (J.G.D.P., Y.M., M.A., H.J.R., F.B.), Division of Cardiology (J.G.D.P., Y.M., M.A., H.J.R., F.B.), Division of Cardiovascular Surgery, Department of Surgery (M.R., J.A., V.R.), Department of Medical Imaging, Peter Munk Cardiac Centre (B.J.W.), Ted Rogers Centre for Heart Research (M.R., H.J.R., F.B., V.R.), and Laboratory Medicine and Pathology (J.B.), Toronto General Hospital, University of Toronto, Canada. , Bernd J. WinterspergerBernd J. Wintersperger From the Department of Medicine (J.G.D.P., Y.M., M.A., H.J.R., F.B.), Division of Cardiology (J.G.D.P., Y.M., M.A., H.J.R., F.B.), Division of Cardiovascular Surgery, Department of Surgery (M.R., J.A., V.R.), Department of Medical Imaging, Peter Munk Cardiac Centre (B.J.W.), Ted Rogers Centre for Heart Research (M.R., H.J.R., F.B., V.R.), and Laboratory Medicine and Pathology (J.B.), Toronto General Hospital, University of Toronto, Canada. , Heather J. RossHeather J. Ross From the Department of Medicine (J.G.D.P., Y.M., M.A., H.J.R., F.B.), Division of Cardiology (J.G.D.P., Y.M., M.A., H.J.R., F.B.), Division of Cardiovascular Surgery, Department of Surgery (M.R., J.A., V.R.), Department of Medical Imaging, Peter Munk Cardiac Centre (B.J.W.), Ted Rogers Centre for Heart Research (M.R., H.J.R., F.B., V.R.), and Laboratory Medicine and Pathology (J.B.), Toronto General Hospital, University of Toronto, Canada. , Jagdish ButanyJagdish Butany From the Department of Medicine (J.G.D.P., Y.M., M.A., H.J.R., F.B.), Division of Cardiology (J.G.D.P., Y.M., M.A., H.J.R., F.B.), Division of Cardiovascular Surgery, Department of Surgery (M.R., J.A., V.R.), Department of Medical Imaging, Peter Munk Cardiac Centre (B.J.W.), Ted Rogers Centre for Heart Research (M.R., H.J.R., F.B., V.R.), and Laboratory Medicine and Pathology (J.B.), Toronto General Hospital, University of Toronto, Canada. , Filio BilliaFilio Billia From the Department of Medicine (J.G.D.P., Y.M., M.A., H.J.R., F.B.), Division of Cardiology (J.G.D.P., Y.M., M.A., H.J.R., F.B.), Division of Cardiovascular Surgery, Department of Surgery (M.R., J.A., V.R.), Department of Medical Imaging, Peter Munk Cardiac Centre (B.J.W.), Ted Rogers Centre for Heart Research (M.R., H.J.R., F.B., V.R.), and Laboratory Medicine and Pathology (J.B.), Toronto General Hospital, University of Toronto, Canada. and Vivek RaoVivek Rao From the Department of Medicine (J.G.D.P., Y.M., M.A., H.J.R., F.B.), Division of Cardiology (J.G.D.P., Y.M., M.A., H.J.R., F.B.), Division of Cardiovascular Surgery, Department of Surgery (M.R., J.A., V.R.), Department of Medical Imaging, Peter Munk Cardiac Centre (B.J.W.), Ted Rogers Centre for Heart Research (M.R., H.J.R., F.B., V.R.), and Laboratory Medicine and Pathology (J.B.), Toronto General Hospital, University of Toronto, Canada. Originally published29 Aug 2017https://doi.org/10.1161/CIRCHEARTFAILURE.117.004275Circulation: Heart Failure. 2017;10:e004275IntroductionContinuous-flow ventricular assist devices have demonstrated clinical superiority compared with the first-generation pulsatile devices; however, complications continue to affect patients on left ventricular assist device (LVAD) support.1 The recently published MOMENTUM 3 trial (Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy With HeartMate3) reported that the HeartMate 3 (HM3) was associated with better outcomes after 6 months when compared with the HM2. None of the patients randomized to the HM3 device had suspected or confirmed thrombosis.2 In this brief report, we describe 2 patients who developed extrinsic occlusion of the outflow graft after HM3 implantation.Case 1A 65-year-old man with ischemic cardiomyopathy underwent implantation of an HM3 LVAD as bridge to transplantation. Because of significant epistaxis, acetylsalicylic acid was reduced from 325 to 81 mg daily, whereas international normalized ratio was maintained between 2 and 3.One-year post-LVAD, the patient presented with congestive symptoms and deteriorating renal function. His LVAD had logged multiple low-flow alarms, as low as 1.9 L/min (previously 4–4.5 L/min; Figure [C]). Serum lactate dehydrogenase was 290 U/L (125–220 U/L) and international normalized ratio maintained within therapeutic range. A noncontrast computed tomographic scan of the chest showed no external cannula compression or malposition. The patient was initiated on intravenous vasodilators, inotropes, and unfractionated heparin. In light of the persistent low flow, he underwent heart transplantation 28 days later. Subsequent pathological examination demonstrated outflow graft impingement by thrombotic material between the bend relief and the outflow graft (Figure [B]). The patient remains alive and well 10 months after transplant.Download figureDownload PowerPointFigure. A high index of suspicion is required for the diagnosis of outflow graft occlusion.A, Longitudinal curved planar reformats of the computed tomographic angiography demonstrate a smooth curvature of the outflow cannula without acute kink. Thrombus formation (arrows) is demonstrated within the bend relief portion of the cannula demonstrating substantial narrowing of the cross-sectional lumen. B and D, Cross-sectional examination demonstrating luminal narrowing of the outflow graft (+) by thrombogenic material contained within the bend relief (*). C and E, Log files obtained from HeartMate 3 (HM3) demonstrating flow decline over time (arrow heads).Case 2A 41-year-old man with dilated cardiomyopathy, morbid obesity, and medication noncompliance underwent HM3 LVAD implantation as a bridge to candidacy. He was discharged from hospital on postoperative day 33 with moderate right ventricle dysfunction requiring high-dose diuretics. Three months later, his daily acetylsalicylic acid dose was reduced to 81 mg because of gastrointestinal bleeding. He remained on warfarin with an international normalized ratio target between 2 and 3.Six months after implant, he reported brief but recurrent low-flow alarms (Figure [E]). Apart from an initial lactate dehydrogenase that was above his baseline (596 U/L), subsequent markers of hemolysis were at baseline, and his international normalized ratio was in therapeutic range. LVAD flows were consistently <2 L/min (baseline 5–5.5 L/min). While on inotropes, an echocardiographic ramp study demonstrated aortic valve opening with every beat at 6300 rpm. Cardiac computed tomographic angiography demonstrated a filling defect within the proximal LVAD outflow conduit consistent with wall adherent thrombus causing significant outflow graft stenosis (Figure [A]). He underwent heart transplantation 14 days later and remains well 5 months post-transplant. At the time of explant, thrombotic material was present between the proximal outflow graft and the bend relief (Figure [D]).DiscussionPump thrombosis occurring at any level is associated with significant morbidity. Outflow graft thrombus can be treated medically, surgically, and rarely with percutaneous stenting,3 and diagnosis requires an algorithmic approach.4 Herein, we describe 2 patients who developed an outer layer thrombus causing near occlusion of the outflow graft at the level of the bend relief. At our center, no other cases of outflow graft compression have been suspected or documented in patients supported with other long-term continuous-flow LVADs (HM2 or HeartWare ventricular assist device). Only one other case of outflow graft thrombosis has been reported in the CE Mark trial (Conformité Européenne); however, the underlying mechanism was not discussed.In the cases described, certain factors may have contributed to this presentation. Both patients required a lower acetylsalicylic acid dose. Although this dose still complies with manufacturer's recommendation, the decreased shearing of von Willebrand Factor high–molecular weight multimers reported with HM3 raises the question as to whether these patients require higher doses of acetylsalicylic acid to avoid thrombotic events.On the basis of the pathological assessment of the explanted devices, we hypothesize that bleeding into the virtual space between the outflow graft and the bend relief resulted in lumen occlusion. The fabric of the outflow graft is porous and could allow leakage of intravascular contents if preparation is inadequate. However, the same outflow graft is used for both HM2 and HM3 devices. Furthermore, the same surgical team has implanted all HM3 at our institution (n=15), making an intrinsic problem with inadequate graft preparation less likely. The HM3 outflow graft is longer and may be at increased risk of external compression; mechanisms resulting in extrinsic impingement include an enlarging right ventricle past the bend relief and the steeper outflow angle with an HM3. It is possible that shear stress could have led to leaking of blood into this virtual space contributing to the thrombotic layer at a microscopic level. We cannot exclude that these 2 cases are isolated events because of circumstantial factors not primarily pump related.SummaryWe present 2 cases of outflow graft occlusion occurring late after HM3 implant highlighting the importance of heightened surveillance as life-threatening adverse events can arise. Further research may help determine medical and surgical considerations that would prevent occlusion of the outflow graft in an HM3 device.DisclosuresDr Rao is a consultant to Medtronic and St Jude Medical. Dr Butany is a consultant to Edwards Life Sciences. All authors had access to the data and contributed to the preparation of this article. The other authors report no conflicts.FootnotesCirc Heart Fail is available at http://circheartfailure.ahajournals.org.Correspondence to: Vivek Rao, MD, PhD, Toronto General Hospital, 4N 457-200 Elizabeth St, Toronto, ON M5G 2C4. E-mail [email protected]References1. 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Stio R, Comisso M, Paolucci L, Coletta S, Cesario V, Gioia M, Nazzaro M, Saitto G, Contento C, D'Avino E, De Felice F, Gabrielli D and Musumeci F (2022) A Redo Percutaneous Emergency Intervention of Left Ventricular Assist Device Graft Occlusion, International Journal of Environmental Research and Public Health, 10.3390/ijerph19105976, 19:10, (5976) Tramontin C, Affronti A and Cirio E (2022) Diagnostic and surgical management of HeartMate 3 outflow graft obstruction due to two different mechanisms, Asian Cardiovascular and Thoracic Annals, 10.1177/02184923221106765, (021849232211067) Troutman G and Genuardi M (2022) Left Ventricular Assist Devices: A Primer for the Non-Mechanical Circulatory Support Provider, Journal of Clinical Medicine, 10.3390/jcm11092575, 11:9, (2575) Fang P, Du J, Boraschi A, Bozzi S, Redaelli A, Schmid Daners M, Kurtcuoglu V, Consolo F and de Zélicourt D (2022) Insights Into the Low Rate of In-Pump Thrombosis With the HeartMate 3: Does the Artificial Pulse Improve Washout?, Frontiers in Cardiovascular Medicine, 10.3389/fcvm.2022.775780, 9 September 2017Vol 10, Issue 9 Advertisement Article InformationMetrics © 2017 American Heart Association, Inc.https://doi.org/10.1161/CIRCHEARTFAILURE.117.004275PMID: 28851717 Manuscript receivedMay 31, 2017Manuscript acceptedJuly 21, 2017Originally publishedAugust 29, 2017 Keywordshemolysisheparinheart transplantationepistaxisthrombosisPDF download Advertisement SubjectsCardiomyopathyCardiovascular SurgeryHeart FailureTransplantation
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