Aortic Root Thrombosis Research Articles

(1202) - Aortic Root Thrombosis After Temporary Mechanical Circulatory Support Implantation - A Case Report

(1202) - Aortic Root Thrombosis After Temporary Mechanical Circulatory Support Implantation - A Case Report

Aortic Root Thrombosis in patients with HeartMate 3 left ventricular assist device support

BackgroundAortic root thrombus (ART) formation is a complication of continuous flow left ventricular assist device (LVAD) therapy. However, the incidence and related complications of ART in HeartMate 3 (HM3) patients remains unknown. MethodsPatients who underwent HM3 implantation from November 2014 through August 2020 at a quaternary academic medical center were included. Demographics and outcomes were abstracted from the medical record. Echocardiograms and contrast-enhanced CT studies were reviewed to identify patients who developed ART and/or moderate or greater aortic insufficiency (AI) on HM3 support. ResultsThe study cohort included 197 HM3 patients with a median post-implant follow-up of 17.5 months. Nineteen patients (9.6%) developed ART during HM3 support, and 15 patients (7.6%) developed moderate or greater AI. Baseline age, gender, race, implantation strategy, and INTERMACS classification were similar between the ART and no-ART groups. ART was associated with an increased risk of death, stroke, or AV intervention (subhazard ratio [SHR] 3.60 [95% CI 1.71-7.56]; p=0.001) and moderate or greater AI (SHR 11.1 [CI 3.60-34.1]; p<0.001) but was not associated with a statistically significantly increased risk of death or stroke on HM3 support (2.12 [0.86-5.22]; p=0.10). Of the 19 patients with ART, 6 (31.6%) developed moderate or greater AI, necessitating more frequent AV interventions (ART: 5 AV interventions [3 surgical repairs, 1 surgical replacement, 1 transcatheter replacement; 26.3%]; no-ART: 0). ConclusionNearly 10% of HM3 patients developed ART during device support. ART was associated with increased risk of a composite endpoint of death, stroke, or AV intervention as well as moderate or greater AI.

Successful management of aortic root thrombosis in a patient with Heartmate 3.

A 74-year-old female with ischemic cardiomyopathy underwent Heartmate 3 (HM 3) implantation for advanced heart failure as destination therapy. Anticoagulation with unfractionated heparin was started within 24 h after implantation. Warfarin and aspirin were started on post-operative Day 3. The patient was mostly in the therapeutic range of the international normalized ratio and activated partial thromboplastin time. On a post-operative Day 11, the patient took a chest computed tomography (CT) for the evaluation of new-onset dyspnea. The CT demonstrated a large aortic root thrombosis (ART) measuring 2.9 cm in maximum diameter covering all three cusps of the aortic valve (AV) (Panel A) and showed a close location with the left coronary ostium (Panel B, arrow: left coronary ostium). After a multidisciplinary discussion with heart failure physicians, cardiac surgeons, and cardiac imaging specialists, we decided to intensify anticoagulation and withhold thrombectomy. We also increased the pump speed in an effort to minimize the AV motion for the prevention of systemic embolization or myocardial infarction. After 3 weeks, follow-up CT showed regression of the ART (Panel C). Accordingly, we lowered the left ventricular assist device (LVAD) pump speed for adequate AV opening to prevent recurrent ART. Three-dimensional (3D) CT reconstruction of the LVAD (Panel D) and follow-up chest x-ray (Panel E) showed well positioned LVAD. The patient was discharged and has been doing well for more than a year with a good therapeutic target range of anticoagulation.

Subclavian versus femoral arterial cannulations during extracorporeal membrane oxygenation: A propensity-matched comparison.

During peripheral extracorporeal veno-arterial membrane oxygenation (VA-ECMO) support, subclavian arterial cannulation provides, in comparison to femoral arterial cannulation, an anterograde flow which may prevent from left ventricular (LV) distention and improve outcomes. We aimed to compare the effectiveness of subclavian cannulation to femoral cannulation in reducing LV overdistension consequences, hemostatic complications and mortality. This retrospective study conducted in two intensive care units of the Lille academic hospitals from January 2013 to December 2019 included 372 non-moribund adult patients supported by VA-ECMO. The primary endpoint was a new onset of pulmonary edema (PO) or LV unloading. Secondary endpoints were myocardial recovery, serious bleeding (according to Extracorporeal Life Support Organization definition), thrombotic complications (a composite of stroke, cannulated limb or mesenteric ischemia, intracardiac or aortic-root thrombosis) and 28 day mortality. Differences in outcomes were analyzed using propensity score matching (PSM) and inverse probability of treatment weighting adjustment (IPTW). As compared to femoral cannulation (n=320 patients), subclavian cannulation (n=52 patients) did not reduce the occurrence of new onset of PO or LV unloading after PSM [HR 0.99 (95% CI 0.51-1.91)]. There was no other difference in outcomes in PSM cohort. In IPTW adjustment cohort, subclavian cannulation was associated with reduced recovery and increased serious bleeding with four accidental decannulations observed. Subclavian artery cannulation was not associated with reduced LV distension related complications, thrombotic complications and 28 day mortality. Rather, it may increase serious bleeding and accidental decannulations, and reduce recovery. Therefore, subclavian cannulation should be limited to vascular accessibility issues.

Native Aortic Root Thrombosis in Single-Ventricle Patients with Native-to-Neoaortic Anastomoses.

In single-ventricle patients with native-to-neoaortic anastomoses, the native aortic root serves as a conduit to the coronary arteries. Thrombosis of the native aortic root has been described only in small, limited reports. We described our center's experience with this rare adverse event. All single-ventricle patients who underwent native-to-neoaortic anastomosis from 2002 to 2017 were compiled from institutional databases. Chart review identified cases of native aortic root thrombosis. Of 467 patients, there were 9 (2%) cases of native aortic root thrombosis; all had hypoplastic left heart syndrome. Timing of thrombosis varied and occurred following each stage of single-ventricle palliation. For treatment, 8 patients received systemic anticoagulation and one patient did not receive any treatment. One patient also underwent percutaneous thrombectomy. Three patients (33.3%) died during the follow-up period. Among survivors, 4/6 had right ventricular systolic function that was mildly depressed or worse at a median follow-up of 8.3years (interquartile range 1.3-10.8). Native aortic root thrombosis is a rare complication occurring at various stages of single-ventricle palliation. In this series, 6 of 9 patients (66.6%) survived; however, ventricular function was often compromised. No risk factors were identified to focus preventative therapies.

The Characteristics and Outcomes of Native Aortic Valve Thrombosis: A Systematic Review

BackgroundThere is a lack of knowledge in the current medical literature about native aortic valve thrombosis. ObjectivesThe aim of this systematic review was to summarize the characteristics, presentations, underlying etiologies, and outcomes of native aortic valve thrombosis and to present a meta-analysis of the best available data. MethodsThe authors performed a literature search, identified published cases of patients with native aortic valve thrombosis, and pooled the data in this meta-analysis. The statistical analysis included calculations of the prevalence of the various presentations, underlying etiologies, aortic cusp involvement, as well as choices of diagnostic testing. They calculated the sensitivities of the various diagnostic testing as well as in-hospital mortality event rates and the univariate ORs of the risk factors for poor outcomes. ResultsThe search strategy and screening process yielded 74 cases of native aortic valve thrombosis, which are included in this meta-analysis. The data revealed that the most common presentation was myocardial infarction in 36%, and the most common underlying etiology was hypercoagulable state in 30%. In-hospital clinical deterioration after presentation including recurrent embolism occurred in ∼38%, and in-hospital mortality rate was ∼20%. ConclusionsNative aortic valve thrombosis is clinically relevant, especially in patients presenting with embolic events. Awareness about native aortic valve or root thrombosis as well as its underlying etiologies, diagnostic work-up, and management is essential, because this condition can be associated with poor outcomes.

The Root of All Thrombi: Coronary Artery Thromboembolism Post Heartmate3

<h3>Introduction</h3> Aortic root thrombosis (ART) is a rare complication of left ventricular assist device (LVAD) therapy and can cause thromboembolic events. We present a case of ART complicated by coronary artery occlusion, myocardial infarction and recurrent ventricular tachycardia (VT) 2 months after HM3 implantation. <h3>Case Report</h3> 62 year old female with non-ischemic cardiomyopathy and HM3 presented 2 months post-implant with chest pain, low flow alarms, and ICD shock. Exam showed MAP 55 mm hg, pump flow 3.4 LPM, speed 5200 RPM, pulsatility index 5.2. LVAD interrogation showed multiple PI events. Her left ventricle was 5.2 cm with closed aortic valve and midline septum. TAPSE was 1.1cm. ECG showed new RBBB. Troponin T peaked at 9035 ng/dL. LDH peaked at 1361 U/L. BNP was 2194 pg/mL. INR range was 2.4-2.7 the month prior. VT initially resolved after decreasing VAD speed to 4800 suggesting suction as a trigger. She received fluids, antiarrhythmics and developed right ventricular dysfunction requiring inotrope support. Persistent chest pain and recurrent VT led to coronary angiography, which showed occlusive thrombus from aortic root to left main and left anterior descending arteries. Using embolic protection devices, clot was mechanically aspirated (Fig 1). Eleven days later, she developed an acute left posterior cerebral and basilar artery stroke. Attempted clot aspiration was complicated by intracranial hemorrhage. <h3>Summary</h3> Hemocompatibility related adverse events remain an issue with the HM 3. Lower rates of pump thrombosis were reported in the MOMENTUM trials, but thrombi can form at other sites such as outflow graft and aortic root, causing embolic complications. Closed aortic valves form a blind pouch, increasing the risk of ART especially if INR is subtherapeutic. Early imaging of the aortic root and coronary arteries should be considered for unexplained VT irrespective of coronary anatomy and risks and benefits of intervention using embolic protection devices can be considered after careful multidisciplinary evaluation.

Life-Threatening But Forgotten Complication After Norwood Operation

Native aortic root thrombosis (NART) after Norwood operation for hypoplastic left heart syndrome (HLHS) is a complication that has only rarely been reported. In this issue of The Annals of Thoracic Surgery, Rajab and Mitchell1 reported 4 cases of NART. A systematic literature search identified 12 publications with 16 cases previously reported. In addition to these 12 publications, there was 1 abstract with 9 cases of NART from University of Michigan in 2018.2

Native Aortic Root Thrombosis After Norwood Palliation for Hypoplastic Left Heart Syndrome

Norwood palliation for hypoplastic left heart syndrome typically results in retrograde perfusion of the native aortic root. This may predispose to native aortic root thrombosis (NART). Patients who underwent stage 1 Norwood palliation at Children's Hospital Colorado between 2003 and 2019 were retrospectively reviewed for NART. Additional patients were identified by a systematic literature review. Patient factors, operative details, presentation, diagnostic methods, treatments, and outcomes were analyzed. Three patients with NART were identified among 241 patients who had undergone stage 1 Norwood palliation at Children's Hospital Colorado (mean follow-up, 48 months). A fourth patient identified at Children's Hospital Colorado had undergone stage 1 palliation elsewhere. The systematic literature review identified 12 additional patients. Among the 16 patients, patients presented with new arrhythmias (38% [n= 6]), evidence of ischemia (31% [n= 5]), incidentally (19% [n= 3]), inability to wean from postoperative support (6% [n= 1]), and cardiac arrest (6% [n= 1). The diagnosis was made by transthoracic echocardiography (TTE) in 50% (n= 8), transesophageal echocardiography in 19% (n= 3), cardiac catheterization in 25% (n= 4), and cardiac computed tomography in 6% (n= 1). Importantly, 44% (n= 7) of patients were missed by TTE and subsequently diagnosed by other methods. Treatment strategies were surgical thrombectomy in 38% (n= 6), anticoagulation alone in 38% (n= 6), direct catheter thrombolysis in 19% (n= 3), and systemic thrombolysis in 6% (n= 1). The rate of mortality or transplant listing was 44% (n= 7). NART is an underappreciated complication of Norwood palliation with high mortality. There should be a high index of suspicion for NART in patients after Norwood palliation with an unexplained complicated clinical course. Importantly, NART is frequently missed by TTE.

Less Invasive Left Ventricular Assist Device Implantation: One Right Step Toward the Future

Less Invasive Left Ventricular Assist Device Implantation: One Right Step Toward the Future

Sternum-Sparing HVAD Implantation with Attachment of the Outflow Graft to the Descending Aorta.

The standard approach for implanting an HVAD left ventricular assist device (LVAD) is performing a median sternotomy and sewing the outflow graft to the ascending aorta. However, in patients with sternal comorbidities, it may be advantageous to use a sternum-sparing approach. We retrospectively studied eight patients who underwent HVAD implantation for destination therapy via a left subcostal or fifth/sixth intercostal space incision. With this procedure, the outflow graft was sewed to the descending aorta. Ninety-day and one-year survival rates were 87.5% and 75%, respectively. Two patients (25%) died during the perioperative period: one from multisystem organ failure and the other from unrelated causes. We adjusted the HVAD speed to open the aortic valve once every three to four beats. Compared with other continuous-flow LVAD implantations performed at our institution during the study period (n = 437), this technique resulted in shorter bypass times and a lower incidence of infection; it was not associated with an increased incidence of heart failure, aortic root thrombosis, pump thrombosis, progression of aortic insufficiency, or ischemic neurologic dysfunction. Our findings suggest that a sternum-sparing approach for HVAD implantation is feasible and may be a safe option in patients with serious comorbidities that preclude the use of traditional implantation techniques.

AORTIC ROOT THROMBUS: A UNIQUE COMPLICATION AFTER LEFT VENTRICULAR ASSIST DEVICE PLACEMENT

Aortic root thrombosis (ART) is an uncommon but life threatening complication after Left ventricular assist device (LVAD) placement. High index of suspicion, prompt diagnosis can avert unfavorable outcome. A 67 yr man with systolic heart failure, ischemic cardiomyopathy underwent HeartMate II LVAD

Aortic root thrombosis in patients supported with continuous-flow left ventricular assist devices.

Aortic root thrombosis (ART) is a recently recognized complication of continuous-flow left ventricular assist device (CF-LVAD) therapy. However, little is known about the prevalence or clinical significance of this complication. The aim of our study was to systematically evaluate the incidence and significance of ART on CF-LVAD support. We retrospectively reviewed all patients who underwent HeartMate II or HeartWare HVAD CF-LVAD implantation from April 2004 through June 2016 at the Columbia University Medical Center. Echocardiography studies were systematically reviewed to identify patients who developed ART. Study outcomes included post-ART survival on CF-LVAD support, stroke, pump thrombosis, and clinically significant myocardial infarction (MI). The study cohort consisted of 436 CF-LVAD patients with 21 patients (4.8%) diagnosed with confirmed ART at a median time of 22 days (interquartile range [IQR] 3 to 56 days) after CF-LVAD implantation. Involvement of the non-coronary cusp was the most common location of the ART (n = 15, 71.4%) and concomitant RV failure occurred in 14 patients (66.7%). Actuarial survival at 1 and 2 years after diagnosis of ART was 73.8% and 44.3%, respectively. ART was associated with a high rate of complications, including stroke (28.6%, 0.337 episode per patient-year [EPPY]) and clinically significant MI (28.6%, 0.337 EPPY). ART is not uncommon after CF-LVAD implantation and is associated with significant morbidity and mortality in CF-LVAD patients. Given the early occurrence and high incidence of stroke and MI in patients who develop ART, surveillance and treatment strategies should be implemented to address this potentially devastating complication.

Letter To The Editor: Management of Aortic Root Thrombosis After Implantation of a Continuous-Flow Left Ventricular Assist Device: A Real Conundrum.

We present a case of aortic root thrombosis in a patient supported with a continuous-flow left ventricular assist device (LVAD), highlight the diagnostic role of echocardiography, and offer some important caveats to consider when managing this rare but potentially devastating complication in

(668) - Correlation of LVAD Outflow Graft Orientation with Aortic Root Thrombosis Rationalized by Patient Specific Computational Fluid Dynamics Simulations

(668) - Correlation of LVAD Outflow Graft Orientation with Aortic Root Thrombosis Rationalized by Patient Specific Computational Fluid Dynamics Simulations

Postoperative Outcomes of the Largest HeartMate-II Experience in Turkey

IntroductionHeartMate II (HMII; Thoratec Corporation, Pleasanton, Calif, United States) is a continuous-flow pump approved by the Food and Drug Administration (FDA) for bridge-to-transplantation (BTT) since 2008 and for destination therapy (DT) since 2010. Herein, we present the postoperative outcomes of HMII implantation due to end-stage heart failure in our center. MethodsTwenty-eight patients (mean age, 51.2 ± 8.7 years; 1 female) were implanted with the HMII between August 2012 and August 2014. Indications were dilated (n = 18) and ischemic (n = 10) cardiomyopathy. The intended treatment was BTT in 24 and DT in 4 patients. Preoperative clinical status was International Registry for Mechanical Circulatory Support (INTERMACS) 2, 3, and 4 in 6, 14, and 8 patients, respectively. The procedure was performed via conventional sternotomy under cardiopulmonary bypass. Heparin, acetylsalicylic acid, and warfarin were used for postoperative anticoagulation. ResultsMean duration of support was 326 days (median, 272). Three patients underwent heart transplantation and 22 remain on pump support. One patient died before discharge due to respiratory failure and 2 others died following a cerebral bleeding 248 and 265 days postoperatively, respectively. The survival rates at 6 and 12 months were 96% and 90%, respectively. Temporary right ventricular failure was observed in 2 patients. Two patients had pump thrombosis treated with anticoagulation management or pump exchange, whereas another patient who had aortic root thrombosis underwent reoperation for removal of the thrombus. DiscussionMechanical circulatory support with HMII axial flow pump seems to be effective and may provide good survival rates compared with optimum medical management and old-generation devices. Patient selection and timing of implantation are crucial for success.

Early Aortic Root and Left Main Coronary Artery Thrombosis after Left Ventricular Assist Device Implantation

We describe a case of 39 years old male, underwent continuous flow LVAD implantation (HeartWare) HVAD as destination therapy (DT) for severe left ventricular dysfunction, moderate right ventricular dysfunction and severe pulmonary hypertension, presented 3rd day post-operatively with polymorphic ventricular tachycardia (VT storm) alternating with VF before aborting to bradycardia and complete heart block. Coronary angiography revealed a big LM coronary artery thrombus extended distally to LCX and LAD arteries and pedunculating into the aortic root proximally, despite full coverage with antiplatelet and anticoagulant therapy. In conclusion, the “take-home message” is: we should be “thrombus minded” for early diagnosis and management of post LVAD implantation aortic root and LM coronary artery thrombosis and it is necessary in improving post-operative outcome. Also, high risk surgical interference in such sick patients can be avoided by early interventional management.

Computational Fluid Dynamic Analysis to Prevent Aortic Root and Valve Clots during Left Ventricular Assist Device Support

Aortic root and valve clots are rare but well described in patients on maximal left ventricular assist device (LVAD) support. We performed a theoretical analysis using computational fluid dynamic analyses in two dimensions to try and ascertain if inflow cannula design/orientation/placement affect aortic root flow dynamics. Two-dimensional computational fluid dynamics using easy CFD-G was performed. The effect of a curved inflow cannula, a straight cannula, and one with a hole in the outer curve was analyzed. In addition, the effect of inflow conduit angulation on the ascending aorta was studied. Computational fluid dynamic (CFD) analysis predicts that stagnant blood exists in the aortic root when little or no cardiac ejection is taking place. Coronary flow is too small to affect the root flow streamlines. A hole on the root side of a curved inflow aortic cannula increases the flow in the aortic root and may decrease the incidence of root and valve thrombosis. The angle of the inflow conduit attachment to the ascending aorta was also found to be crucial with regard to aortic root blood stasis. In addition, a baffle at the tip of the inflow cannula may prove to be beneficial. Theoretical analysis using the technique of CFD predicts that inflow cannula position and design may affect the incidence of aortic root thrombosis during LVAD support when minimal cardiac ejection is occurring.

Aortic root thrombosis after transhiatal esophagectomy: A case report

Aortic root thrombosis after transhiatal esophagectomy: A case report

Thrombus Formation in the Native Aortic Root in Patients with Hypoplastic Left Heart Syndrome

Thrombus formation in the native aortic root is a rare but potentially life-threatening complication in patients with hypoplastic left heart syndrome. The native aortic root in these patients serves as a conduit for the retrograde filling of the coronary arteries. Thrombus in this location could result in myocardial ischemia. We present three cases of native aortic root thrombosis at our institution with clinical presentations ranging from asymptomatic to sudden cardiac arrest. Our experience with these patients argues for careful and consistent evaluation of the native aortic root regardless of clinical symptoms.