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Durable Left Ventricular Assist Device Outflow Graft Obstructions: Clinical Characteristics and Outcomes
Carli J Peters1,2, Robert S Zhang3, Mahesh K Vidula1,2
1Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA.
Insights
Outflow graft obstruction is a rare complication in patients with left ventricular assist devices (LVADs). Computed tomography angiography (CTA) aids in diagnosis, and endovascular stenting can treat external compression.
Area of Science:
- Cardiology
- Medical Devices
- Surgical Complications
Background:
- Left ventricular assist devices (LVADs) are crucial for end-stage heart failure management.
- Outflow graft obstruction is a potential, albeit uncommon, complication of LVAD support.
- Early identification and management are vital for patient outcomes.
Purpose of the Study:
- To describe the clinical course and management of patients with LVADs who developed outflow graft obstructions.
- To evaluate the diagnostic utility of various imaging modalities.
- To report on treatment strategies and outcomes.
Main Methods:
- Retrospective review of patients with LVAD support from 2012-2020.
- Identification of patients diagnosed with outflow graft obstruction via computed tomography angiography (CTA) or angiogram.
- Analysis of patient characteristics, clinical presentation, diagnostic methods, and management strategies.
Main Results:
- 11 out of 324 LVAD patients (3.4%) developed outflow graft obstructions.
- Low flow alarms were the most common presentation (10/11 patients).
- CTA was effective for non-invasive diagnosis in 8/11 patients; endovascular stenting successfully treated extrinsic compression in 3 patients.
Conclusions:
- Outflow graft obstructions are rare but serious LVAD complications, potentially underestimated due to non-specific symptoms.
- CTA is a key non-invasive diagnostic tool.
- Endovascular stenting is an effective treatment for extrinsic compression of the outflow graft.
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.
