The effect of LVAD aortic outflow-graft placement on hemodynamics and flow: Implantation technique and computer flow...

Axial-flow ventricular assist devices (VADs) can be implanted either through a left thoracotomy with outflow-graft anastomosis to the descending thoracic aorta or through a midline sternotomy with anastomosis to the ascending aorta. Each method has advantages and disadvantages. Because these VADs produce nonpulsatile flow, their hemodynamic characteristics differ from those of pulsatile devices. These differences may have important clinical consequences, particularly in relation to the outflow-graft configuration. We describe a computer-generated flow model that we created to illustrate the flow dynamics and possible clinical consequences of each method. The simulations indicate that the location of the anastomosis has important qualitative effects on flow in the ascending aorta and aortic arch. At high VAD outputs (> or =75%), native cardiac output cannot supply the carotid and subclavian arteries. With a descending aortic anastomosis, net backward flow occurs in the descending aorta to supply these branches. Consequently, the aortic arch has a region with almost no net flow, where fluid particles stagnate over many cardiac cycles, possibly causing thrombogenesis. With an ascending aortic anastomosis, the arch has no stagnant region, although flow turbulence still occurs. When the aortic valve remains closed, so that the total output occurs through the VAD, the aortic root has a region of nearly stagnant flow. With an ascending aortic anastomosis, a small degree of recirculatory flow may prevent complete stagnation at the aortic root. With the descending aortic anastomosis, however, no recirculation occurs. These results help delineate the complex flow dynamics and the advantages and drawbacks of each technique.