Cardiovascular and Interventional Radiology

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Presentation transcript:

Cardiovascular and Interventional Radiology Endovascular Stenting of a Left Ventricular Assist Device (LVAD) Outflow Graft Stenosis Will Johnson, MD Neil Halin, DO Tufts Medical Center Cardiovascular and Interventional Radiology NESIR Meeting 2/13/2017

Patient Case 47 Y M hx of NICM, LVEF 10-15%, EtOH abuse Heartware LVAD as bridge to transplant 3/13/2014 Heartware LVAD Exchange due to thrombus 2/18/2015 Persistent low flows on LVAD Currently in 2-3 L/min range; previously had been 3.5 to 4.5 L/min Admitted to Tufts MC for further workup CTA Chest obtained

Heartware LVAD

LVAD Outflow Graft Stenosis Multidisciplinary Meeting -Cardiothoracic Surgery -Interventional Radiology -Heart Failure LVAD exchange with CT surgery Thoracotomy/open surgery High morbidity Second LVAD exchange in < 2 years Endovascular Approach Lower morbidity Familiarity with approach No thrombus seen on CT

LVAD Outflow Graft Stenosis Balloon Expandable Bare Metal Stent No thrombus Appropriate for kink Covered Stent Thrombus Pseudoaneurysm Hematoma

LVAD Outflow Graft Stenosis Balloon Expandable Stents in areas of stenosis 10 mm x 37 mm Boston Scientific (proximal stenosis) 10 mm x 37 mm Visi-Pro Balloon (distal stenosis) LVAD motor RPM decreased during ballooning LVAD RPM’s returned to normal following stent placement

Post Procedural LVAD flow Pulsatility Discharged POD 4 Improved to 4.9 L/min from 1.9 L/min prior to procedure Pulsatility BP waveform demonstrated pulsatility prior to procedure indicating LV participation Monophasic, suggests offloading of left ventricle by LVAD Discharged POD 4 LVAD flows 5-6 L/min by time of DC

Post Procedure Outpatient F/U 1 month post op Improved energy Mild dyspnea on exertion, otherwise minimal heart failure symptoms One dose of torsemide due to dietary indiscretion Improved flow (one low flow alarm) No hospitalizations UNOS 1A for heart transplant

Literature Review

Literature Review

Acknowledgements Neil Halin, DO Tufts Medical Center, Cardiovascular and Interventional Radiology Tufts Medical Center, Department of Radiology

References Pham, D.T., Kapur, N.K., Dermody, M, Halin, N. (2015). Stenting of an outflow graft obstruction after implantation of a continuous-flow, axial-flow left ventricular assist device. The Journal of Thoracic and Cardiovascular Surgery, 150, e11-12 Ganapathi, A., Andersen, N., Prastein, D., Hashmi, Z., Rogers, J., Milano, C., McCann, R., Hughes, G.C. (2013) Endovascular Stent Grafting of a Left Ventricular Assist Device Outflow Graft Pseudoaneurysm. Circ Heart Fail, 6, e16-e18 Hanke, J., ElSherbini, A., Rojas, S., Avsar, M., Shrestha, M., Schmitto, J. (2016) Letters to the Editor: Aortic Outflow Graft Stenting in Patient with Left Ventricular Assist Device Outflow Graft Thrombosis. Artificial Organs, 40(4): 414-418 Ahmad, F., Sauer, A., Ricciardi, M. (2016) Endovascular Repair of Ventricular Assist Device Outflow Cannula Stenosis. Catheterization and Cardiovascular Interventions. Published online 10/12/2016 El Sabbagh, A. Al-Hijji, M. Gulati, R., Charanjit, S., Pollak, P., Behfar, Atta. Percutaneous Stenting of a Left Ventricular Assist Device Outflow Kink. (2016) Cardiovascular Interventions. 9(24): e229-e231 Abraham, J., Remick, J., Caulfield, T., Puhlman, M., Evenson, K., Ott, G., Kirker, E. (2014) Left Ventricular Assist Device Outflow Cannula Obstruction Treated with Percutaneous Endovascular Stenting. Circ Heart Fail, 8, 229-230