Left Ventricular Assist Device Performance Under Pressure: Troubleshooting Outflow Graft Dysfunction.

Abstract

HomeCirculation: Heart FailureVol. 13, No. 7Left Ventricular Assist Device Performance Under Pressure Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toSupplementary MaterialsFree AccessResearch ArticlePDF/EPUBLeft Ventricular Assist Device Performance Under PressureTroubleshooting Outflow Graft Dysfunction Mark N. Belkin, MD, Joseph Venturini, MD, Sandeep Nathan, MD, MSc and Jonathan Grinstein, MD Mark N. BelkinMark N. Belkin Section of Cardiology, University of Chicago Medicine, Chicago, IL. Search for more papers by this author , Joseph VenturiniJoseph Venturini Section of Cardiology, University of Chicago Medicine, Chicago, IL. Search for more papers by this author , Sandeep NathanSandeep Nathan Section of Cardiology, University of Chicago Medicine, Chicago, IL. Search for more papers by this author and Jonathan GrinsteinJonathan Grinstein Correspondence to: Jonathan Grinstein, MD, Section of Cardiology, University of Chicago, Chicago, IL, Email E-mail Address: [email protected] https://orcid.org/0000-0002-7053-8928 Section of Cardiology, University of Chicago Medicine, Chicago, IL. Search for more papers by this author Originally published1 Jul 2020https://doi.org/10.1161/CIRCHEARTFAILURE.120.007098Circulation: Heart Failure. 2020;13:e007098A 38-year-old morbidly obese male with nonischemic cardiomyopathy status-post HeartMate 3 (Abbott Laboratories, Abbott Park, IL) left ventricular assist device (LVAD) as destination therapy in September 2018, presented 18 months later with cardiogenic shock. Initial right heart catheterization, at an LVAD speed of 6200 rpm, suggested elevated biventricular pressures with reduced cardiac output. Transthoracic echocardiogram noted an enlarged left ventricle with a rightward septum, aortic valve opening, and no significant aortic regurgitation. The patient was started on dobutamine, but fluid removal was difficult. Repeat transthoracic echocardiogram and right heart catheterization at LVAD speed 6300 rpm and higher vasoactives revealed a larger left ventricle and continued poor hemodynamics.In the setting of left ventricular dilation with aortic valve opening despite high speeds, and mild increase in lactic dehydrogenase levels, concern for LVAD malfunction was raised. Logfile analysis was unrevealing. Chest X-Ray did not demonstrate obvious device defects when compared to prior. Computed tomography angiography to evaluate for outflow graft obstruction was deferred due to persistent renal dysfunction. Instead, the patient underwent invasive hemodynamic assessment of the outflow graft. There was no obvious deformity of the outflow graft by digital-subtraction angiography, but end-hole catheter pullback measurement revealed a significant pressure gradient (98 mm Hg peak/80 mm Hg mean) in the proximal portion near the LVAD bend relief (Figure 1A and 1B; Movie I in the Data Supplement). The patient went to the operating room where outflow graft twisting was noted 3 cm from the connector to the device body. The connector was rotated 120 degrees to fully untwist the obstruction (Figure 2). The patient was monitored afterwards in the ICU as vasoactive medications were weaned off and his LVAD function, renal function, and volume status improved.Download figureDownload PowerPointFigure 1. (A) Invasive hemodynamic pressure measurement of left ventricular assist device (LVAD) outflow graft. (B) Fluoroscopy of cardiac catheter position within LVAD outflow graft. Arrow indicates catheter tip at point of pressure gradient.Download figureDownload PowerPointFigure 2. Operative images of outflow graft kink (A) before and (B) after untwisting. The arrow in (A) indicates outflow graft kink; and the arrow in (B), outflow graft after untwisting of kink.Measurement of the gradient in the outflow graft can be used to differentiate pump thrombosis from an outflow graft abnormality in patients with a clinical concern for device malfunction.DisclosuresNone.FootnotesThe Data Supplement is available at https://www.ahajournals.org/doi/suppl/10.1161/CIRCHEARTFAILURE.120.007098.Correspondence to: Jonathan Grinstein, MD, Section of Cardiology, University of Chicago, Chicago, IL, Email [email protected]bsd.uchicago.edu Previous Back to top Next FiguresReferencesRelatedDetails July 2020Vol 13, Issue 7Article InformationMetrics Download: 349 © 2020 American Heart Association, Inc.https://doi.org/10.1161/CIRCHEARTFAILURE.120.007098PMID: 32605386 Originally publishedJuly 1, 2020 Keywordsangiographytomographyhemodynamicsleft ventricular assist devicePDF download SubjectsCardiomyopathyHeart Failure