Cerebral protection during percutaneous intervention for left ventricular assist device outflow graft obstruction

Abstract

Background Left ventricular assist devices (LVAD) outflow graft obstruction is an uncommon complication but carries significant morbidity and mortality. Here we provide a case series of patients with LVAD intrinsic outflow graft obstruction who are deemed to be a high surgical risk for pump exchange and, therefore, underwent percutaneous intervention with the concomitant use of neuroprotective device—Sentinel cerebral protection system (CPS) (Boston Scientific) to prevent embolic stroke. Methods We retrospectively analyzed patients who underwent LVAD placement in our institution and developed LVAD outflow graft obstruction. The diagnosis of LVAD outflow graft obstruction was confirmed by utilizing various cardiac imaging modalities such as echocardiography and/or computed tomography angiography. All patients were treated with percutaneous intervention and a catheter‐based CPS. Results From a total of 501 LVAD implants in our institute, 6 (1.2%) patients with LVAD outflow graft obstruction who underwent percutaneous treatment were included; 4 patients with HeartMate‐III LVAD, 1 patient with HeartMate‐II LVAD, and 1 patient with HeartWare (HVAD). The median age of patients was 56.5 years at the time of LVAD implantation. The median time from the LVAD implantation to the episode of LVAD outflow obstruction was 1343 days. Utilization of Sentinel CPS resulted in the capture and removal of thrombus/debris in all patients. Conclusions Percutaneous intervention of LVAD outflow graft obstruction is less invasive than surgical pump exchange and an acceptable alternative in properly selected patients. In our experience, utilization of a catheter‐based CPS can help in reducing the incidence of periprocedural embolic events.

Outcomes of outflow graft stenting in HeartMate 3 left ventricular assist devices: A systematic review and individual patient data meta‐analysis

“…Thirteen studies 6,9–20 and one unpublished case (performed at Thomas Jefferson University Hospital) were used for analysis, yielding a total of 28 patients with HM3 outflow graft stenosis that underwent stenting. Patient‐level data were extracted for statistical analysis.…”

“…Carotid embolic protection was employed in 25% of patients, with studies citing lower complication rates when embolic protection was used in various other cardiac surgeries or using embolic protection as a precaution for outflow graft thrombosis 9,13,18 . Of those who received protection, 42.9% had an occlusive thrombus as the cause of outflow obstruction.…”

“…Carotid embolic protection was employed in 25% of patients, with studies citing lower complication rates when embolic protection was used in various other cardiac surgeries or using embolic protection as a precaution for outflow graft thrombosis. 9,13,18 Of those who received protection, 42.9% had an occlusive thrombus as the cause of outflow obstruction. With only two patients in our study having a neurological event after stenting, the necessity of employing carotid embolic protection for the HM3 in nonthrombotic occlusions should be explored further.…”

Percutaneous Stenting of a Stenotic Berlin Heart Outflow Cannula Graft in a 2-Year-Old Child

“…The clonus and CT finding of multifocal hemorrhage may have been linked to thrombotic showering before during or after the intervention; the subtlety of the clinical change makes it difficult to be sure; however embolic events are certainly a risk in such a procedure. In a larger patient, the placement of a cerebral protection device should be considered 9 ; we did not feel that this would have been appropriate in a 12 kg patient given currently available devices. Additionally, other potential complications of this procedure include embolic stroke, bleeding, and infection as with any other catheterization, although notably higher in these high-risk heavily anticoagulated patients.…”