Outflow Graft Occlusion with Vascular Plug as Interventional Alternative for LVAD Discontinuation

Objectives: Myocardial recovery after primary left ventricular assist device (LVAD) implantation is a rare observation, especially in ischemic cardiomyopathy patients. Just turning-off of the LVAD system is not an option due to the severe back-flow from the outflow graft into the left ventricle in LVAD systems with no valves (axial and centrifugal flow pumps). An operative approach with complete removal of the pump via sternotomy is always a re-do operation with the need for the heart-lung-machine. A lateral approach with an off-pump LVAD removal might be an alternative, but is quite invasive, too.

We report our experience from switching from complete removal via sternotomy and off-pump lateral approach to an interventional approach with outflow graft occlusion.

Methods: In 5 patients (4 men, 1 woman; average age 61.6 ± 8.1 years; 2 Thoratec-Abbott HeartMate II, 3 HeartWare-Medtronic HVAD) the assist device was explanted due to myocardial recovery in three and infection in two cases.

Results: In the first two patients complete removal via median sternotomy was performed due to myocardial recovery in one (HeartMate II) and infection (HVAD) in the other patient. Both patients died in multi-organ-failure (MOF) on day 23 resp. 33 post-explant. In one case an off-pump lateral approach was performed due to LVAD pocket infection (HVAD). This patient died 16 days after removal in MOF.

In the last two cases with myocardial r the LVAD was turned off in the cath laboratory and a vascular plug (Amplatzer Vascular Plug II, St. Jude Medical; 14 mm for HVAD and 18 mm for HeartMate II) was directly interventionally implanted in the outflow graft to prevent back-flow. Thereafter the driveline was cut via a small substernal incision and completely removed in a 15 minute operation. A stay on the intensive unit was not necessary and both patients could be discharged two days later. Both patients are now 66 and 96 days out of the hospital with a turned-off LVAD in situ without any problems.

Conclusion: The interventional approach in outflow graft occlusion and LVAD deactivation is a very attractive and feasible option. The procedure is straight forwarded due to the known diameter of the outflow graft of the devices. A re-do operation with a postoperative intensive care stay, bleeding and need for heart-lung-machine could be completely avoided. No side-effects were seen so far with the inflow graft inside the left ventricle with ongoing anticoagulation with Coumadin and platelet inhibition.