Author + information
- Received August 13, 2013
- Revision received September 16, 2013
- Accepted September 26, 2013
- Published online June 1, 2014.
- ∗University of Washington Medical Center, Seattle, Washington
- †David Geffen School of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, California
- ↵∗Reprint requests and correspondence:
Dr. Ali Nsair, Advanced Heart Failure/Mechanical Support/Heart Transplant Program, David Geffen School of Medicine, Ronald Reagan UCLA Medical Center, 100 Medical Plaza Drive, Suite 630, Los Angeles, California 90095.
A 55-year-old man with nonischemic dilated cardiomyopathy who had undergone HeartMate II (HM2) (Thoratec, Pleasanton, California) implantation for destination therapy was readmitted 1.5 years later because of low-flow alarms with dizziness. Transesophageal echocardiogram showed decreased velocity proximal to the HM2 outflow–aortic anastomosis, raising concerns for obstruction, and flow acceleration distal to the anastomosis (Fig. 1). His left ventricular end-diastolic diameter (LVEDD) was 59 mm. Inflows were estimated at 0.6 m/s (Fig. 2), velocity within the outflow cannula was 0.5 m/s, and outflow–aortic anastomosis velocity was 1.9 m/s. Computed tomography angiograms confirmed the outflow cannula was stenotic near the aortic insertion (Fig. 3), with a reference diameter in the Dacron graft of 16 mm and narrowing to 8 mm × 12 mm near the anastomosis.
He was felt to be too high risk for surgery, and it was decided to attempt percutaneous angioplasty. A 4-F cut pigtail catheter and straight 0.035-inch wire was used to access the outflow cannula. Reference vessel diameter was 14 to 15 mm, and the region of stenosis was 8 to 9 mm in diameter (Fig. 4). An Amplatz 0.035-inch Super Stiff guidewire (St. Jude Medical, Golden Valley, Minnesota) was placed in the mid-cannula retrograde through the outflow graft, and a 14 mm × 4-cm Cordis Opta-Pro balloon angioplasty balloon (Cordis Corp., Miami, Florida) was inflated twice at the anastomosis to a maximal pressure of 4 atm. There was resolution of the waist narrowing with the second inflation (Figs. 5 and 6⇓⇓, Online Videos 1 and 2). During each inflation, HM2 flow was decreased transiently to 1 l/min for 3 to 4 s at a time. Post-angioplasty, Doppler flow velocity at the anastomosis improved from 1.9 m/s to 1 m/s. LVEDD decreased from 59 mm to 39 mm. The patient was discharged 4 days later, and HM2 function has remained stable to date, 6 months post-angioplasty.
The incidence of outflow graft stenosis in the intermediate to long-term setting post–left ventricular assist device implantation is not well documented. It is likely that even though the occurrence is low, it remains underdiagnosed except in the most severe cases. Percutaneous approaches offer an attractive alternative to surgical intervention in this high-risk group by avoiding re-do sternotomy.
For accompanying videos, please see the online version of this paper.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received August 13, 2013.
- Revision received September 16, 2013.
- Accepted September 26, 2013.
- American College of Cardiology Foundation