Author + information
- Received September 12, 2016
- Accepted September 26, 2016
- Published online December 19, 2016.
- Abdallah El Sabbagh, MDa,
- Mohammed Al-Hijji, MDa,
- Rajiv Gulati, MD, PhDa,
- Charanjit S. Rihal, MDa,
- Peter M. Pollak, MDb and
- Atta Behfar, MD, PhDa,∗ ()
- aDepartment of Cardiovascular Diseases, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
- bDivision of Cardiovascular Diseases, Mayo Clinic and Mayo Foundation, Jacksonville, Florida
- ↵∗Reprint requests and correspondence:
Dr. Atta Behfar, Department of Cardiovascular Disease, Mayo Clinic, 200 First Street Southwest, Rochester, Minnesota 55905.
A 70-year old man with end-stage ischemic cardiomyopathy status post HeartMate II (Thoratec, Pleasanton, California) left ventricular assist device (LVAD) implantation as destination therapy presented with recurrent gastrointestinal bleeding. He was seen by gastroenterology and had a work-up that revealed proximal jejunal angiodysplasia. Device parameters revealed a high velocity of his pump with evidence of poor decompression of the left ventricle on the transthoracic echocardiogram. Computed tomography angiography of the chest revealed a 90° angulation in the LVAD proximal outflow cannula with no cannula thrombosis (Figure 1). It was thought that this outflow obstruction is causing acquired von Willebrand’s disease, which was confirmed by a von Willebrand factor multimer analysis testing.
Through femoral access and a JR4 diagnostic catheter (Cordis, Miami, Florida), the graft was cannulated retrogradely with the stiff angled Glidewire (Terumo Medical Corporation, Somerset, New Jersey). This led to unkinking the grafts and provided immediate improvement with robust increase in the LVAD flow.
The Glidewire was then exchanged with an extra stiff wire then a Lunderquist wire (Cook Medical, Bjaeverskov, Denmark) with upsizing of the femoral sheath for better support. A 20 × 55 mm WallStent self-expanding stent (Boston Scientific, Natick, Massachusetts) was delivered to unkink the LVAD outflow graft (Figure 2A). The stent was positioned distally and deployed (Figure 2B), followed by post-dilation (Figure 2C) with a Z-Med balloon (NuMED, Inc., Hopkinton, New York).
The patient had excellent angiographic results (Figure 2D, Online Video 1) and hemodynamic response based on the LVAD settings (Figure 3). There were no complications associated with the procedure. Repeat computed tomography angiography showed the stent in place with decrease in the angulation of the kink (Figure 4, Online Video 2). On a 2-year follow up visit, the patient had not had any further GI bleeding (Figure 5) and device monitoring highlighted improved flow dynamics.
For supplemental videos and their legends, please see the online version of this article.
All authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received September 12, 2016.
- Accepted September 26, 2016.
- American College of Cardiology Foundation