Cases of Surgical Intervention for Outflow Graft Obstruction Due to Accumulation of Biodebris Following HeartMate 3 Implantation

Abstract

<h3>Introduction</h3> Outflow graft obstruction due to accumulation of biodebris between the outflow graft and bend relief has been reported following implantation of the HeartMate 3 (HM3) LVAD. In some instances, this can result in significant hemodynamic compromise, warranting operative intervention. We present three cases in which outflow graft obstruction was successfully relieved with operative excision of the HM3 bend relief and evacuation of biodebris. <h3>Case Report</h3> (1) 43 yr-old male with NICM s/p HM3 as bridge to transplantation presented with persistent low flow alarms at 26 months post-LVAD. CTA demonstrated outflow graft occlusion. Via subcostal incision, the patient underwent evacuation of biodebris with resolution of flow obstruction. The patient was subsequently discharged to home on postoperative day 7. (2) 38 y/o female with NICM s/p HM3 developed low flow alarms acutely during admission for GI symptoms 17 months post LVAD. CTA interpreted as "filling defect in midportion of outflow graft." The patient underwent urgent exploration via subxiphoid approach. With excision of the bed relief and evacuation of biodebris, the patient had immediate improvement in her pump flow. The patient was discharged to home on postoperative day 11. (3) 77 y/o male with NICM who underwent HM3 implantation as destination therapy. The patient presented with episodic low flow alarms 25 months post LVAD implantation. CTA demonstrated accumulation of biodebris within the course of the bend relief. The patient underwent excision and evacuation via subxiphoid approach. The patient was discharged to home on postoperative day 6. Images from CTA of the outflow graft (arrows) both pre and postoperatively are shown in Figure 1. <h3>Summary</h3> When intervention is deemed necessary, outflow graft occlusion due to accumulation of biodebris in HM3 patients can be treated surgically, with minimal morbidity. Biodebris evacuation can be effectively achieved through either a subxiphoid or subcostal approach.