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• W3121010686 abstract "HomeCirculation: Heart FailureVol. 14, No. 1Uncommon Cause of Hemolysis With Rapid Decrease in Mechanical Circulatory Support Flow Free AccessCase ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toSupplementary MaterialsFree AccessCase ReportPDF/EPUBUncommon Cause of Hemolysis With Rapid Decrease in Mechanical Circulatory Support Flow Taylor Nordan, BS Jamel Ortoleva, MD Frederick Y. Chen, MD, PhD Navin K. Kapur, MD Gregory S. Couper, MD Masashi KawaboriMD Taylor NordanTaylor Nordan Department of Cardiac Surgery (T.N., F.Y.C., G.S.C., M.K.), Tufts Medical Center, Boston, MA. Search for more papers by this author , Jamel OrtolevaJamel Ortoleva Department of Anesthesiology and Perioperative Medicine (J.O.), Tufts Medical Center, Boston, MA. Search for more papers by this author , Frederick Y. ChenFrederick Y. Chen Department of Cardiac Surgery (T.N., F.Y.C., G.S.C., M.K.), Tufts Medical Center, Boston, MA. Search for more papers by this author , Navin K. KapurNavin K. Kapur https://orcid.org/0000-0002-8302-6796 Department of Cardiology (N.K.K.), Tufts Medical Center, Boston, MA. Search for more papers by this author , Gregory S. CouperGregory S. Couper Department of Cardiac Surgery (T.N., F.Y.C., G.S.C., M.K.), Tufts Medical Center, Boston, MA. Search for more papers by this author , Masashi KawaboriMasashi Kawabori Correspondence to: Masashi Kawabori, MD, 800 Washington St, Boston, MA 02111. Email E-mail Address: [email protected] https://orcid.org/0000-0002-3580-5664 Department of Cardiac Surgery (T.N., F.Y.C., G.S.C., M.K.), Tufts Medical Center, Boston, MA. Search for more papers by this author Originally published13 Jan 2021https://doi.org/10.1161/CIRCHEARTFAILURE.120.007312Circulation: Heart Failure. 2021;14:e007312Right ventricular failure following left ventricular assist device implantation, cardiotomy, or myocardial infarction imparts a grim prognosis.1 If the right ventricle cannot move adequate volume through the lungs to the left side of the heart, cardiac output will suffer with potential development of cardiogenic shock. Thus, several devices, implanted surgically or percutaneously, have been developed to support a tenuous right ventricle. We present a case of severe hemolysis secondary to thrombus formation on the tip of a caged-tip outflow cannula in a patient with surgically implanted CentriMag (Abbott, Chicago, IL) right ventricular assist device (RVAD) support.Case ReportA 61-year-old female with a history of ischemic cardiomyopathy was transferred from an outside affiliated hospital for advanced heart failure treatment. She developed severe right ventricular failure subsequent to HeartMate 3 (Abbott, Chicago, IL) implantation through median sternotomy at the outside affiliated hospital. Central RVAD support was established with inflow to the right atrium and outflow to the main pulmonary artery (mPA) using a CentriMag circuit at the outside affiliated hospital. On admission to our institution, RVAD speed was 3500 revolutions per minute with flow of 3.5 liters per minute. Left ventricular assist device speed was 5300 revolutions per minute with flow of 4.1 liters per minute and pulsatility index of 5.0. The patient was hemodynamically stable without signs of volume overload. Systemic heparin produced anticoagulation in therapeutic range with anti-Xa level consistently between 0.4 and 0.6 IU/L. LDH (lactate dehydrogenase) level was 886 IU/L.One week after admission to our institution, RVAD flow abruptly decreased without revolutions per minute changes. Left ventricular assist device power and flow remained unchanged. RVAD speed was increased to 4300 revolutions per minute to maintain 4.1 liters per minute. LDH spiked to 1781 IU/L, leading to suspicion of hemolysis due to thrombosis of the RVAD inflow or outflow cannula. Contrast computed tomography demonstrated potential filling defects around the RVAD outflow cannula (Figure [A]). LDH jumped further to 4107 IU/L.Download figureDownload PowerPointFigure. The images of developed thrombus on caged tip cannula.A, Contrast computed tomography demonstrates a filling defect in the main pulmonary artery (mPA). B, Transesophageal echocardiogram demonstrates massive thrombus in the main pulmonary artery. C, Gross pathology demonstrates severe narrowing of outflow ports (yellow arrows) due to thrombus formation; the blue arrow marks the caged tip. D, Medtronic Soft-Flow arterial cannula. RVAD indicates right ventricular assist device.The patient was taken to the operating room for mediastinal exploration. The patient was placed on cardiopulmonary bypass. Right atriotomy revealed a patent 32F malleable RVAD inflow cannula. Intraoperative transesophageal echocardiogram revealed a mass in the mPA (Figure [B], Movie in the Data Supplement). The mPA was incised, and the RVAD outflow cannula was gently removed. Gross examination demonstrated a 2.0 cm×1.7 cm×0.4 cm mass at the tip of the cannula with near occlusion of the efflux ports (Figure [C]). By removing the clot, the cannula was confirmed to be a 24F Soft-Flow (Medtronic, Minneapolis, MN) arterial cannula, which has a caged tip (Figure [D]). The RVAD circuit was exchanged with implantation of a new 24F CentriMag end-hole RVAD outflow cannula. LDH rapidly normalized with resumption of adequate biventricular support.SummaryWe present an unusual cause of severe hemolysis due to RVAD outflow cannula thrombus formation in a patient supported with HeartMate 3 left ventricular assist device and CentriMag RVAD. Severe hemolysis with high-hemocompatibility mechanical circulatory support device, such as the CentriMag or HeartMate 3, is rare.2 Caged tip outflow cannulae may increase the risk of thrombus formation in mid-term to long-term mechanical circulatory support. Other surgeons at our institution have observed this complication with use of caged-tip outflow cannulae in the mPA. Data demonstrate that caged-tip cannulae dampen flow against the arterial wall, which may protect against atheroemboli formation when placed in the aorta.3 However, this effect is likely trivial with regard to pulmonary artery cannulation due to low atherosclerotic burden. Since the venous system has slower flow and may contain debris from the lower extremities or indwelling catheters that could lodge in the caged-tip, our institution preferably uses end-hole catheters as RVAD outflow in the mPA.4Nonstandard Abbreviations and AcronymsLDHlactate dehydrogenasemPAmain pulmonary arteryRVADright ventricular assist deviceSources of FundingNone.Disclosures None.FootnotesThis article was sent to Daniel Burkhoff, MD, PhD, Guest Editor, for review by expert referees, editorial decision, and final disposition.The Data Supplement is available at https://www.ahajournals.org/doi/suppl/10.1161/CIRCHEARTFAILURE.120.007312.For Sources of Funding and Disclosures, see page 154.Correspondence to: Masashi Kawabori, MD, 800 Washington St, Boston, MA 02111. Email kawabori.[email protected]comReferences1. Lampert BC, Teuteberg JJ. Right ventricular failure after left ventricular assist devices.J Heart Lung Transplant. 2015; 34:1123–1130. doi: 10.1016/j.healun.2015.06.015CrossrefMedlineGoogle Scholar2. John R, Long JW, Massey HT, Griffith BP, Sun BC, Tector AJ, Frazier OH, Joyce LD. Outcomes of a multicenter trial of the levitronix CentriMag ventricular assist system for short-term circulatory support.J Thorac Cardiovasc Surg. 2011; 141:932–939. doi: 10.1016/j.jtcvs.2010.03.046CrossrefMedlineGoogle Scholar3. Grooters RK, Ver Steeg DA, Stewart MJ, Thieman KC, Schneider RF. Echocardiographic comparison of the standard end-hole cannula, the soft-flow cannula, and the dispersion cannula during perfusion into the aortic arch.Ann Thorac Surg. 2003; 75:1919–1923. doi: 10.1016/s0003-4975(03)00018-3CrossrefMedlineGoogle Scholar4. Lumb AB. Chapter 11: Nonrespiratory functions of the Lung.Lumb AB, ed. In Nunn’s Applied Respiratory Physiology Eighth Edition, New York: Elsevier; 2017:203–214.Google Scholar Previous Back to top Next FiguresReferencesRelatedDetails January 2021Vol 14, Issue 1Article InformationMetrics Download: 57 © 2020 American Heart Association, Inc.https://doi.org/10.1161/CIRCHEARTFAILURE.120.007312PMID: 33435696 Originally publishedJanuary 13, 2021 Keywordsmechanical circulatory supporthemolysisheart failureright ventricular assist devicethrombusPDF download SubjectsTreatmentCardiovascular SurgeryHeart Failure" @default.
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