Anterior Thoracotomy Approach to Address Late-Stage LVAD Outflow Graft Obstruction

History of Presenting Illness 

The patient was a 37-year-old female with a history of ischemic cardiomyopathy due to spontaneous coronary dissection and a status post HeartMate 3 LVAD placement in June 2019, complicated by recurrent driveline infections. She presented with unresponsiveness and low LVAD flows. Over the previous several days, she had experienced lightheadedness and dizziness, which she had attributed to hot weather. On the day she arrived, she had developed watery diarrhea, increased dizziness, and loss of consciousness. In the emergency department, she received IV fluids and began to respond. Her LVAD flows were noted to be below 2 L/min. Blood work revealed a supratherapeutic INR and elevated lactate levels. A CTA showed a proximal outflow graft obstruction. Due to the obstruction's proximal location, percutaneous intervention was not feasible, and surgical revision was required. 

Procedure 

The patient was prepped and draped in the supine position with the left side elevated. A mini anterior thoracotomy incision was made over the left fifth intercostal space. The outflow graft and bend relief were found to be fused to the rib immediately beneath the endothoracic fascia. Consequently, a portion of the fifth rib was excised, directly encountering the bend relief. Using a #15 blade, the bend relief was carefully opened, revealing liquefied proteinaceous material. The opening was expanded, and a significant amount of material was cleared from the proximal outflow graft. Following this, LVAD flows improved from 2 L/min to 4 L/min, and the pulsatility index dropped from 9 to 4. The areas were then irrigated, a drain was placed, and the wound was closed in layers.

Disclaimer

The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.