Agrawal Akanksha, Alexy Tamas, Kamioka Norihiko, Shafi Taimur, Stowe Judson, Morris Alanna A, Vega J David, Babaliaros Vasilis, Burke Michael A
Division of Cardiology, Department of Medicine, Emory University School of Medicine, 101 Woodruff Circle, Suite 322, Atlanta, GA, 30322, USA.
Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA.
ESC Heart Fail. 2021 Jun;8(3):2349-2353. doi: 10.1002/ehf2.13333. Epub 2021 Mar 30.
Outflow graft obstruction is a poorly described complication following left ventricular assist device (LVAD) surgery. We sought to define the incidence of LVAD outflow graft obstruction and assess clinical outcomes with a percutaneous treatment strategy.
From January 2012 to October 2020, 322 patients with LVAD were managed at our institution. Patients with LVAD outflow graft obstruction were identified by cardiac computed tomography with angiography and invasive haemodynamic assessment and were subsequently treated with percutaneous intervention. Poisson regression was used to analyse time-dependent differences in the incidence of LVAD outflow graft obstruction. Kaplan-Meier analysis was used to estimate survival. Twenty patients (6.2%) developed haemodynamically significant LVAD outflow graft obstruction at a rate of 0.03 events per patient-year. Outflow graft obstruction presented a median of 33 (26-49) months after surgery. Patients presented with low estimated LVAD pump flow (95%), heart failure (90%), or both (85%), and 59% developed cardiogenic shock prior to intervention. The most common aetiology identified by cardiac computed tomography with angiography was external compression of the outflow graft (78%). On presentation, the median peak gradient in the outflow graft was 78 (64-100) mmHg. Outflow graft stenting was 100% successful with no in-hospital mortality, and it reduced the peak outflow graft gradient to 10 (2-17) mmHg (P < 0.001). Outflow graft stenting was durable with two patients (10%) requiring a repeat procedure over a median follow-up of 13 (7-20) months and did not impact survival.
Left ventricular assist device outflow graft obstruction is a relatively common and underappreciated cause of recurrent heart failure and LVAD dysfunction. Outflow graft stenting can be achieved with low morbidity and provides a long-term solution to this complication.
流出道移植物梗阻是左心室辅助装置（LVAD）手术后一种描述较少的并发症。我们试图确定LVAD流出道移植物梗阻的发生率，并评估经皮治疗策略的临床结局。
2012年1月至2020年10月，我院共收治322例LVAD患者。通过心脏计算机断层扫描血管造影和有创血流动力学评估确定LVAD流出道移植物梗阻患者，随后对其进行经皮介入治疗。采用泊松回归分析LVAD流出道移植物梗阻发生率的时间依赖性差异。采用Kaplan-Meier分析评估生存率。20例患者（6.2%）发生血流动力学显著的LVAD流出道移植物梗阻，发生率为0.03例/患者年。流出道移植物梗阻发生在术后中位时间33（26 - 49）个月。患者表现为LVAD泵流量估计值低（95%）、心力衰竭（90%）或两者兼有（85%），59%的患者在介入治疗前发生心源性休克。心脏计算机断层扫描血管造影确定的最常见病因是流出道移植物外部受压（78%）。就诊时，流出道移植物的中位峰值压差为78（64 - 100）mmHg。流出道移植物支架置入术成功率为100%，无院内死亡病例，且将流出道移植物峰值压差降至10（2 - 17）mmHg（P < 0.001）。流出道移植物支架置入术效果持久，中位随访13（7 - 20）个月期间，2例患者（10%）需要重复手术，且不影响生存率。
左心室辅助装置流出道移植物梗阻是复发性心力衰竭和LVAD功能障碍的一个相对常见且未得到充分认识的原因。流出道移植物支架置入术可实现低发病率，并为该并发症提供长期解决方案。
