Interact CardioVasc Thorac Surg 2009;8:661-662. doi:10.1510/icvts.2009.202242
© 2009 European Association of Cardio-Thoracic Surgery
Negative results - Assisted circulation |
Aortic valve thrombosis after implantation of temporary left ventricular assist device
Juan A. Crestanelloa,*,
David A. Orsinellib,
Michael S. Firstenberga and
Chittoor Sai-Sudhakara
a Division of Cardiothoracic Surgery, The Richard M. Ross Heart Hospital, The Ohio State University Medical Center, Columbus, OH, USA
b Division of Cardiology, The Richard M. Ross Heart Hospital, The Ohio State University Medical Center, Columbus, OH, USA
Received 7 January 2009;
received in revised form 24 February 2009;
accepted 25 February 2009
*Corresponding author. Division of Cardiothoracic Surgery, The Ohio State University, 816 Doan Hall, 410 W 10th Ave, Columbus, OH 43210, USA. Tel.: +1 (614) 293-7277; fax: +1 (614) 293-4726.
E-mail address: juan.crestanello{at}osumc.edu (J.A. Crestanello).
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Abstract
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The use of assist devices for ventricular support after myocardial infarction with cardiogenic shock has become common practice. Thrombosis, bleeding, and infection are common complications. However, native valve thrombosis is a rare complication. We present a case of aortic valve thrombosis after implantation of a left ventricular assist device (LVAD) treated with thrombus removal at time of device exchange.
Key Words: Heart failure; Myocardial infarction; Thrombosis; Valves; Echocardiography
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1. Introduction
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Ventricular assist devices are commonly used for hemodynamic support after myocardial infarction. Their implantation is associated with decreased intra-cardiac circulation and blood stagnation. However, valve thrombosis is a rare complication associated with their implantation [1, 2]. We present a case of aortic valve thrombosis after implantation of a left ventricular assist device (LVAD) treated with thrombus removal at time of device exchange.
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2. Case report
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A 44-year-old male presented in cardiogenic shock after a ventricular fibrillation cardiac arrest. Coronary angiography demonstrated acute occlusion of the left anterior descending and right coronary arteries. The left ventricular ejection fraction was 15% with severe global hypokinesis. There was severe right ventricular dysfunction. Emergent coronary artery bypass surgery to the left anterior descending coronary artery, obtuse marginal, and right coronary artery was performed. Temporary right and left ventricular assist devices were instituted as a bridge to recovery utilizing Levitronix CentriMag (Thoratec Corp, Pleasanton, CA) centrifugal blood pumps. Left-sided cannulation was performed in the apex of the left ventricle (inflow) and distal ascending aorta (outflow). Intraoperative transesophageal echocardiogram at the time of the initial surgery revealed a normal aortic valve with normal leaflet mobility and no valve stenosis nor insufficiency. Anticoagulation with heparin was initiated 24 h after implantation. The PTT was maintained between 57 and 70 s. Aspirin (81 mg) was administered daily.
A transesophageal echocardiogram was performed 10 days after the initial surgery to evaluate for cardiac function recovery. Left ventricular function remained severely depressed (10–15%). In addition, there was minimal mobility of the right and left coronary cusps of the aortic valve with layering of thrombus on their aortic surface (Fig. 1a, b, Videos 1 and 2). In contrast, the aortic valve left coronary cusp had normal mobility (Fig. 1a, b, Videos 1 and 2). At surgery, organized thrombus was visualized on the aortic surface of the right and non-coronary leaflets of the aortic valve extending into their corresponding sinuses of Valsalva (Fig. 1c). The thrombus was moderately adherent to the leaflets and sinuses of Valsalva requiring the utilization of an endarterectomy spatula for its removal (Fig. 1d). The temporary left ventricular support device was exchanged for a HeartMate II LVAD (Thoratec Corp, Pleasanton, CA) for long-term support. Significant improvement in the function of the right ventricle enabled successful explantation of the right ventricular assist device.
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Fig. 1. (a) Transesophageal echocardiogram: mid-esophageal short axis view of the aortic valve demonstrating echo dense material in the non- (NC) and right-coronary (RC) cusps. (b) Transesophageal echocardiogram: mid-esophageal long axis view demonstrating aortic valve thrombus in the right coronary cusp (arrows). (c) Intraoperative view of the aortic valve and ascending aorta. Note thrombus in the right (RC) and non-coronary (NC) aortic cusps. The left cusp (LC) is free of thrombus. (d) Removed specimen: organized clot forming a cast of the aortic valve cusps. Ao, ascending aorta; LV, left ventricle; LA, left atrium; RC, aortic valve right coronary cusp; LC, aortic valve left coronary cusp; NC, aortic valve non-coronary cusp.
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Video 1. Transesophageal echocardiogram: mid-esophageal short axis view of the aortic valve with LVAD off. Note normal motion of the left coronary cusp of the aortic valve. The right and non-coronary cusps of the aortic valve show no mobility and thrombus.
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Video 2. Transesophageal echocardiogram: mid-esophageal long axis view of the aortic valve with LVAD off. Note minimal motion of the right and non-coronary cusps of the aortic valve and thrombus layering on their aortic surface.
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Normal mobility of the aortic valve leaflets, competence of the valve, and absence of thrombus was confirmed by pre-discharge echocardiogram. The patient was discharged to a rehabilitation center three weeks later following an uncomplicated recovery.
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3. Discussion
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Aortic valve and ascending aorta thrombosis can occur after placement of LVAD despite adequate anticoagulation [1]. It is more common in patients with prosthetic valves, continuous flow devices, and with devices with outflow grafts anastomosed to the descending thoracic aorta [1–3]. These conditions lead to stagnant flow in the aortic valve cusps and ascending aorta generating thrombogenic conditions [3]. In addition, lack of left ventricular ejection with persistent closure of the aortic valve creates further stagnation in the aortic cusps and contributes to thrombosis [3]. Prevention of aortic valve thrombosis can be accomplished by adjusting LVAD flows to allow some or intermittent left ventricular ejection. Left ventricular ejection opens the aortic valve decreasing stagnant flow and thrombogenicity [3].
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References
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- Rao V, Slater JP, Edwards NM, Naka Y, Oz MC. Surgical management of valvular disease in patients requiring left ventricular assist device support. Ann Thorac Surg 2001;71:1448–1453.[Abstract/Free Full Text]
- Barbone A, Rao V, Oz MC, Naka Y. LVAD support in patients with bioprosthetic valves. Ann Thorac Surg 2002;74:232–234.[Abstract/Free Full Text]
- DiGiorgi PL, Smith DL, Naka Y, Oz M. In vitro characterization of aortic retrograde and antegrade flow from pulsatile and non-pulsatile ventricular assist devices. J Heart Lung Transpl 2004;23:186–192.[CrossRef][Medline]
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Abstract
1. Introduction