“Percutaneous” technique for direct external access to and stenting of obstructed pediatric ventricular assist device inflow cannula

Central MessageWe used a novel approach to access the Berlin Heart inflow cannula stent obstructed Gore-Tex chimney apparatus, resulting in relief of obstruction and resolution left atrial hypertension.See Commentary on page XXX. We hypertension. See The EXCOR pediatric ventricular assist device (VAD) is preferred durable mechanical support small infants.1Conway J. St. Louis Morales D.L.S. Law S. Tjossem C. Humpl T. Delineating survival outcomes children <10 kg bridged transplant or recovery with heart device.JACC (J Am Coll Cardiol): Fail. 2015; 3: 70-77https://doi.org/10.1016/j.jchf.2014.07.011Crossref PubMed Scopus (113) Google Scholar,2Almond C.S. D.L. Blackstone E.H. Turrentine M.W. Imamura M. Massicotte M.P. et al.Berlin for bridge transplantation US Children.Circulation. 2013; 127: 1702-1711https://doi.org/10.1161/CIRCULATIONAHA.112.000685Crossref (379) Scholar Alternative cannulation strategies have emerged better restrictive ventricles. Mechanical malfunctions include outflow obstructions secondary thrombosis, fibrin deposit, malposition-related kinking/twisting, infection.3Slaughter M.S. Pagani F.D. Rogers J.G. Miller L.W. Sun B. Russell S.D. al.Clinical management continuous-flow devices advanced failure.J Lung Transplant. 2010; 29: S1-S39https://doi.org/10.1016/j.healun.2010.01.011Abstract Full Text PDF (743) Although there are reports endovascular stenting VAD cannulas, interventions within cannulas rarely reported, direct external has been described only once.4Abraham Remick J.D. Caulfield Puhlman Evenson K. Ott G. al.Left treated percutaneous stenting.Circ: 8: 229-230https://doi.org/10.1161/CIRCHEARTFAILURE.114.001891Crossref (30) Scholar, 5Carr S.M. Lubbe D.F. Huber P.R. Percutaneous transcatheter balloon dilatation stenosis device: LVAD.Cathet Cardiovasc Intervent. 2017; 89: 1219-1223https://doi.org/10.1002/ccd.27061Crossref (3) 6Crompton Hermuzi A. Crossland D. De Rita F. Adhvaryu Nassar A stenotic graft housing by utilizing an adapted circuit.J Card Surg. 2022; 37: 3991-3994https://doi.org/10.1111/jocs.16812Crossref (1) describe hybrid facilitate obstruction. patient's legal guardian (mother) provided verbal consent publication study data; Institutional Review Board approval was not required. female infant Shone's-like complex underwent aortic coarctation mitral valve repair at 75 days age. Left (LA) hypertension persisted diastolic dysfunction stenosis. At age 5 months, she implantation decompress LA while awaiting transplantation. previously strategy which 10-mm-diameter ringed “chimney” extended from through right atriotomy anastomosed surgically created septal defect.7Dykes J.C. Rosenthal D.N. Ma Almond Zafar Peng D.M. al.Atrial circulatory support.J 2021; 40: S96https://doi.org/10.1016/j.healun.2021.01.320Abstract This offers enhanced unloading, advantageous physiology. On day 201, incomplete pump filling noted. Progressive emesis rising brain natriuretic peptide level prompted surveillance catheterization, revealed pulmonary capillary wedge pressure (PCWP) 24 mmHg, indicating hypertension, preserved cardiac index 4.0 L/min/m2 thermodilution. rate increased, immediate decrease PCWP 17 mm Hg. Following these maneuvers, persistent edema, acute kidney injury, ventilator dependence ongoing filling. computed tomography (CT) scan demonstrated longitudinal narrowing residual lumen 2 3 mm, suggestive circumferential mural clot (Figure 1, A). standard prophylactic anticoagulation regimen, including bivalirudin clopidogrel, continued. surgical risk replacement deemed very high given prior sternotomies, size, comorbid state, thus hybrid-based preferable. objective minimizing risks air embolus, (2) new formation, prolonged interruption support. our equipment detail Figure 2.Figure 2A, 6-mm (black thin arrow) disconnected temporarily attached silicone Pleur-Evac tubing thick using 1/4″-to-3/8″ straight connector (white arrow). connected Pedimag 3/8″-to-1/4″ configuration includes option internal jugular venous limb Y-connector if additional hemodynamic required during periods when clamped. (The can be placed position black dashed arrow.) oxygenator membrane. membrane existing patient cannula, ascending aorta. B, distal clamped (thick white (C) Using Seldinger technique, 18G introducer needle preloaded 0.035″ Magic Torque guidewire introduced into tubing. An 8 Fr Flexor Ansel long sheath lubricated saline flush over end chimney. formed tight seal around sheath. Care taken exit avoid perturbation contents. dilator removed, upper vein. D, GORE Viabahn VBX implanted transesophageal fluoroscopic guidance. E, hemostatic underwater wire manipulation, limit entrainment. intermittently (B). F, Explanted demonstrating stented its insertion G, Preserved explanted following dissection away stent, revealing no thrombus deposition account narrowing.View Large Image ViewerDownload Hi-res image Download (PPT) had normal systolic function native opening periprocedural thromboembolism via ejection. vein prepared possible extracorporeal oxygenation reduce preload opening. In brief, exchanged 2). served as filter prevent aspirated entrained entering cannula. intervening segment between inserted technique Given potential entrainment manipulation valve, submerged under water, system catheter manipulation. Angiography 2.4 C, Video 1). × 29 covered echocardiography (TEE) guidance TEE monitoring throughout evidence embolization. CT head before procedure sequential scans after thromboembolic event. extubated later orthotopic 246. 2, G H). that thrombus, alternative theorized mechanism progressive stretching luminal result shift decompression reduced size LA, well growth, predisposing twisting stretching. Close low threshold cross-sectional acquisition patients supported malfunction essential detect such disturbances cannulas. Direct we accurately diagnose intervene detection dysfunctional eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI3ZGM4NGFkMzlkMjYxZjBhNGJlNTc4MGQxNTNmN2E2NCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjk0ODE1NjU2fQ.dwe6IDhTjiNHcdibxdBQEtvb_yy-1aiQ0jp76Ok93-ej_aRFOQFvebNaSmjb7DFpWsJQR6_SWBjgOKSwmdqHbzfOkVzOTUsr0KvyZ1YE0S2GWUsyFUBWZ0ex4e6LXmItuBY6ssgoYZG4vzSV2du0Q4OHU0C_3MuwHnUAjgX0voWOefllAtIRMULYJqhdEA9hxDkSzksavAxTrk9LUqi_khDm986IMducXhyZD4FrS2-DHJwrRl2p2syuUiDoi324UVFeerSucZGwyb1fEaOUrpUZR4Rnycgf1OLKR2a_hOcqJ4J6KwnYXntNRKhWcDbV5tw179Cg_MI_UsKR0kr5xA .mp4 (1.69 MB) Help files 1As shown lateral projection angiography ring proximal atrium. available at: https://www.jtcvs.org/article/S2666-2507(23)00272-9/fulltext. .jpg (.41 https://www.jtcvs.org/article/S2666-2507(23)00272-9/fulltext.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIyOTJkNWIwZmQ5OTY1NzU0YWRhMWYzOGQ4NWM3Y2RiZCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjk0ODE1NjU2fQ.ip_4KbARHTcMFw7yGKFM-ZT6Mut4qDpbukyAvwFqC0-3JKKKN-HgODTWm879NpllTBB5xfuY11WncF1kfH5oYzDkluqu7NhqQ2m1QkKoZcLYo18FSafWP9a8W4Ne7Ylwyp-RVjB_BktyVvCCM4dkrNy-VJ7ezd-tPv5aSyFR1w15UMfaR1enB_uEytii1G44Ff9rDNY08BzYZ5B3_WA0bttTn5fdpdgdmgOlzstUbFY9Lc_J1Is65mXv4bM394NLyzfrFhegHCVuI6DP11kCE_vut-2tk1w90UE9qvR9Z63RF8H6JB8G-e60yKC3P50zSnLQ1nENaelkrsXFPLHu0Q (1.11 2As unobstructed flow atrium