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Goldstein DJ, Kanwar M, Cowger J, Patel S, Meyer DM, Molina E, Salerno C, Elmer A, Schettle S, Teuteberg J, Pagani F, Stehlik J. Extrinsic Outflow Graft Obstruction of the HeartMate 3 LVAD: A State-of-the-Art Review. J Heart Lung Transplant 2024:S1053-2498(24)01739-X. [PMID: 39019352 DOI: 10.1016/j.healun.2024.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 06/27/2024] [Accepted: 07/09/2024] [Indexed: 07/19/2024] Open
Abstract
While notable improvements in survival, incidence of hemocompatibility-related adverse events, hospitalizations and cost have been demonstrated with the only commercially available durable left ventricular assist device, a category of pump malfunctions characterized by outflow graft obstruction has been noted with broader use and clinical follow up of recipients of this technology. Of particular concern, is the accumulation of acellular biodebris between the outflow graft and bend relief covering the outflow graft at its origin with the pump (which we term extrinsic outflow graft obstruction at the bend relief, or EOGO-BR). This process tends to be insidious, occurs late in the postoperative course, can be challenging to diagnose, and can result in significant morbidity and mortality. Herein we provide a review of this complication and outline diagnostic, treatment and preventive strategies.
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Affiliation(s)
- Daniel J Goldstein
- Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY.
| | - Manreet Kanwar
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh PA
| | - Jennifer Cowger
- Cardiovascular Medicine, Henry Ford Medical Center, Detroit, MI
| | - Snehal Patel
- Division of Cardiology, Montefiore Medical Center, Bronx, NY
| | - Dan M Meyer
- Department of Cardiovascular Surgery, Baylor Scott and White Health, Dallas, TX
| | - Ezequiel Molina
- Piedmont Heart Institute - Samsky Advanced Heart Failure Center, Atlanta, GA
| | - Christopher Salerno
- Department of Surgery, University of Chicago School of Medicine and Medical Center, Chicago, IL
| | - Ashley Elmer
- Division of Cardiac Surgery, University of Utah, Salt Lake City, UT
| | - Sarah Schettle
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Jeffrey Teuteberg
- Division of Cardiovascular Medicine, Stanford University, Palo Alto, CA
| | - Francis Pagani
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI
| | - Josef Stehlik
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, UT
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Wert L, Stewart GC, Mehra MR, Milwidsky A, Jorde UP, Goldstein DJ, Selzman CH, Stehlik J, Alshamdin FD, Khaliel FH, Gustafsson F, Boschi S, Loforte A, Ajello S, Scandroglio AM, Tučanová Z, Netuka I, Schlöglhofer T, Zimpfer D, Zijderhand CF, Caliskan K, Dogan G, Schmitto JD, Maier S, Schibilsky D, Jawad K, Saeed D, Faerber G, Morshuis M, Hanuna M, Müller CS, Mulzer J, Kempfert J, Falk V, Potapov EV. A multicenter evaluation of external outflow graft obstruction with a fully magnetically levitated left ventricular assist device. J Thorac Cardiovasc Surg 2024; 167:1322-1330.e6. [PMID: 36562497 DOI: 10.1016/j.jtcvs.2022.09.051] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 09/18/2022] [Accepted: 09/26/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND The HeartMate 3 (HM 3; Abbott) left ventricular assist device (LVAD) has improved hemocompatibility-related adverse outcomes. In sporadic cases, external compression of the outflow graft causing obstruction (eOGO) can result from substance accumulation between the outflow graft and its bend relief. We sought to evaluate the prevalence, course, and clinical implications of eOGO in an international study. METHODS A multicenter retrospective analysis of HM 3 LVADs implanted between November 2014 and April 2021 (n = 2108) was conducted across 17 cardiac centers in 8 countries. We defined eOGO as obstruction >25% in the cross-sectional area in imaging (percutaneous angiography, computed tomography, or intravascular ultrasound). The prevalence and annual incidence were calculated. Serious adverse events and outcomes (death, transplantation, or device exchange) were analyzed for eOGO cases. RESULTS Of 2108 patients, 62 were diagnosed with eOGO at a median LVAD support duration of 953 (interquartile range, 600-1267) days. The prevalence of eOGO was 3.0% and the incidence at 1, 2, 3, 4, and 5 years of support was 0.6%, 2.8%, 4.0%, 5.2%, and 9.1%, respectively. Of 62 patients, 9 were observed, 27 underwent surgical revision, 15 underwent percutaneous stent implantation, 8 received a heart transplant, and 2 died before intervention. One patient underwent surgical revision and later stent implantation. The mortality with therapeutic intervention was 9/53 (17.0%). CONCLUSIONS Although uncommon, HM 3 LVAD-supported patients might develop eOGO with an increasing incidence after 1 year of support. Although engineering efforts to reduce this complication are under way, clinicians must maintain a focus on early detection and remain vigilant.
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Affiliation(s)
- Leonhard Wert
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.
| | - Garrick C Stewart
- Division of Cardiovascular Medicine, Center for Advanced Heart Disease, Brigham and Women's Hospital, Boston, Mass
| | - Mandeep R Mehra
- Division of Cardiovascular Medicine, Center for Advanced Heart Disease, Brigham and Women's Hospital, Boston, Mass
| | - Assi Milwidsky
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Ulrich P Jorde
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Daniel J Goldstein
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Craig H Selzman
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Josef Stehlik
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Faisal D Alshamdin
- King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Feras H Khaliel
- King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Silvia Boschi
- Department of Cardiac Surgery, IRCCS Bologna, S. Orsola University Hospital, Bologna, Italy
| | - Antonio Loforte
- Department of Cardiac Surgery, IRCCS Bologna, S. Orsola University Hospital, Bologna, Italy
| | - Silvia Ajello
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute and Vita-Salute San Raffaele University, Milan, Italy
| | - Anna M Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute and Vita-Salute San Raffaele University, Milan, Italy
| | - Zuzana Tučanová
- Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ivan Netuka
- Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Thomas Schlöglhofer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Casper F Zijderhand
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Kadir Caliskan
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Günes Dogan
- Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jan D Schmitto
- Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Sven Maier
- Department of Cardiovascular Surgery, Heart Center University Freiburg-Bad Krozingen, Freiburg, Germany; Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - David Schibilsky
- Department of Cardiovascular Surgery, Heart Center University Freiburg-Bad Krozingen, Freiburg, Germany; Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Khalil Jawad
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
| | - Diyar Saeed
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
| | - Gloria Faerber
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University Jena, Jena, Germany
| | - Michiel Morshuis
- Department of Thoracic and Cardiovascular Surgery, Heart and Diabetes Centre NRW, Ruhr-University of Bochum, Bad Oeynhausen, Germany
| | - Maja Hanuna
- Department of Cardiac Surgery, Ludwig Maximilian University of Munich, Munich, Germany
| | - Christoph S Müller
- Department of Cardiac Surgery, Ludwig Maximilian University of Munich, Munich, Germany
| | - Johanna Mulzer
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Jörg Kempfert
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany; Department of Cardiothoracic Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany; Department of Health Sciences and Technology, ETH Zürich, Zurich, Switzerland
| | - Evgenij V Potapov
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
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Morshuis M, Fox H, Lauenroth V, Schramm R. Long-term assist device patients admitted to ICU: Tips and pitfalls. JOURNAL OF INTENSIVE MEDICINE 2023; 3:81-88. [PMID: 37188121 PMCID: PMC10175735 DOI: 10.1016/j.jointm.2022.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 10/04/2022] [Accepted: 10/19/2022] [Indexed: 05/17/2023]
Abstract
Left ventricular assist device (LVAD) therapy is well-established in the treatment of end-stage cardiac failure. Indications are bridge to transplant (BTT), bridge to candidacy (BTC), bridge to recovery (BTR), and destination therapy (DT). The durability and adverse event (AE) rate of LVADs have improved over the years. However, due to donor shortage, the duration of support in the BTT population has increased tremendously; similarly, DT patients are on the device for a long time. Consequently, the number of readmissions of long-term LVAD patients has increased. In cases of severe AEs, intensive care unit (ICU) treatment can be necessary. Infectious complications are the most common AE. Furthermore, embolic or hemorrhagic strokes can occur due to foreign surfaces, acquired von Willebrand syndrome, and anticoagulation treatment. Another consequence of the coagulative status, in combination with the continuous flow, are gastrointestinal bleeding events. Moreover, in most patients, an isolated LVAD is implanted, and this involves the risk of late right heart failure. Adjustment of pump speed and optimization of the volume status can help solve this issue. Malignant arrhythmias, pre-existing or de novo after LVAD implantation, can be a life-threatening AE. Antiarrhythmic medical therapy or ablation are potential treatment options. As for specific LVADs, the Medtronic HeartWare™ ventricular assist device (HVAD) is not manufactured and distributed currently; however, 4000 patients are still on the device. Pump thrombosis can occur, wherein thrombolytic therapy is the first-line treatment option. Additionally, the HVAD can fail to restart after controller exchange due to technical issues, and precautions must be taken. The Momentum 3 trial showed superior survival without pump exchange or disabling stroke in patients treated with the HeartMate 3Ⓡ (HM3; Abbott, Abbott Park, IL, USA) device in comparison to the HeartMate II (HMII). However, in a few cases, a twisted graft or bio debris formation between the outflow graft and bend relief could be observed, causing outflow graft obstruction. Patients on LVADs are still heart failure patients, in many cases with comorbidities. Therefore, many situations can occur requiring ICU treatment. Ethical aspects should always be the focus when taking care of these patients.
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Affiliation(s)
- Michiel Morshuis
- Corresponding author: Michiel Morshuis, Heart and Diabetes Center North Rhine-Westphalia, Bad Oeynhausen 32545, Germany.
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Peters CJ, Zhang RS, Vidula MK, Giri J, Atluri P, Acker MA, Bermúdez CA, Levin A, Urgo K, Wald J, Mazurek JA, Hanff TC, Goldberg LR, Jagasia D, Birati EY. Durable Left Ventricular Assist Device Outflow Graft Obstructions: Clinical Characteristics and Outcomes. J Clin Med 2023; 12:jcm12062430. [PMID: 36983430 PMCID: PMC10058609 DOI: 10.3390/jcm12062430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 03/06/2023] [Accepted: 03/19/2023] [Indexed: 03/30/2023] Open
Abstract
PURPOSE We report on the clinical course and management of patients supported with durable implantable LVADs who developed outflow graft obstructions at a large academic center. METHODS We performed a retrospective review of patients receiving LVAD support from 2012 through 2020. Patients who developed an outflow graft obstruction diagnosed by computed tomography angiography (CTA) or angiogram were identified, and patient characteristics and outcomes were reported. RESULTS Of the 324 patients supported by LVAD at our institution, 11 patients (3.4%) were diagnosed with outflow graft obstructions. The most common presentation was low flow alarms, which was present in 10/11 patients, and the remaining patient presented with lightheadedness. Patients had minimal LDH elevation with 8/11 presenting with less than 2-fold the upper limit of normal. Transthoracic echocardiograms were not diagnostic, but CTA enabled non-invasive diagnoses in 8/11 of the patients. Three patients with extrinsic compression of the outflow graft successfully underwent endovascular stent placement, and three patients with outflow cannula kinks received supportive care. Of the five patients diagnosed with intraluminal thromboses, one received a heart transplant, one underwent an outflow graft revision, and three received supportive care due to comorbidities. CONCLUSION Outflow graft obstructions remain a rare, but serious complication. The true prevalence of this entity is likely underestimated due to the non-specific clinical presentation. CTA is a pivotal non-invasive diagnostic step. Patients with external compression were successfully treated with endovascular stenting.
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Affiliation(s)
- Carli J Peters
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Robert S Zhang
- Division of Cardiovascular Medicine, NYU Langone Health, New York, NY 10016, USA
| | - Mahesh K Vidula
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Jay Giri
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Pavan Atluri
- Cardiothoracic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Michael A Acker
- Cardiothoracic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Christian A Bermúdez
- Cardiothoracic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Allison Levin
- Division of Cardiology, Duke University Medical Center, Durham, NC 27710, USA
| | - Kim Urgo
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Joyce Wald
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Jeremy A Mazurek
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Thomas C Hanff
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - Lee R Goldberg
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Dinesh Jagasia
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Edo Y Birati
- The Lydia and Carol Kittner, Lea and Benjamin Davidai Cardiovascular Division, Tzafon (Poriya) Medical Center, Azrieli Faculty of Medicine, Bar-Ilan University, Ramat Gan 5290002, Israel
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