Trans-atrial Inflow Cannula Configuration for Durable HeartWare Left Ventricular Assist Device in Hypertrophic Cardiomyopathy: A Case Series and a Word of Caution.

BACKGROUND/OBJECTIVES: Implantation of a durable left ventricular assist device (LVAD) in patients with hypertrophic cardiomyopathy (HCM) is technically challenging. We describe our experience using a trans-atrial inflow cannulation and a left atrial-to-aorta (LA-Ao) LVAD configuration. Pump hemodynamics, selection criteria, technical considerations, and postoperative management reflections are discussed.

METHODS

Three patients who underwent centrifugal pump implantation using LA-Ao configuration between January 2019 and May 2021 at our institution were reviewed. Patient characteristics, hemodynamics, pump parameters, outcomes are presented.

RESULTS

All patients (2 males, 1 female, aged: 40-64 years-old) had end-stage heart failure secondary to HCM and were INTERMACS Profile 3. Two patients were successfully bridged to transplantation after four months of support, and one patient died from pump thrombosis and stroke. Compared with the left ventricle-to aorta (LV-Ao) confirmation, the variations of the pump flow through the cardiac cycle are inversed in the LA-Ao configuration, and the pressure head is higher leading to a reduced pump-flow at a fixed pump speed. The presence of severe bi-atrial enlargement is an important selection criterion.

CONCLUSION

LA-Ao LVAD configuration might be an alternative for durable LVAD implantation in highly selected candidates with small left ventricular cavity. Post-operative management should account for the higher risk of pump thrombosis related to a reduced trans-pump flow in this configuration.