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Intermittent obstruction of left ventricular assist device due to prolapsing papillary muscle Clint G Humpherys, Steven T Morozowich, Harish Ramakrishna Department of Anesthesiology, Section of Cardiothoracic Anesthesia, Mayo Clinic College of Medicine, Mayo Clinic Arizona, Phoenix, AZ, USA
Common causes of left ventricular assist device (LVAD) inflow cannula obstruction include hypovolemia, thrombus and cannula impingement against the interventricular septum or the ventricular free wall. [1] Obstruction due to the left ventricular papillary muscles is less commonly considered[2] and, to the best of our knowledge, there are only two reports of this: one diagnosed with echocardiography[3] and the other found at autopsy.[4] We present intraoperative transesophageal echocardiography (TEE) images of the anterior papillary muscle prolapsing into an LVAD inflow cannula [Figure 1, Video 1] resulting in elevated inflow velocities with intermittent
obstruction [Figure 2] in a 47-year-old male with biventricular assist device support post acute myocardial infarction, coronary artery bypass grafting and mitral valve replacement with subsequent resection due to prosthetic thrombosis. He presented to the operating room on this occasion for sternal closure and the evaluation of low-LVAD flows refractory to standard therapy. Our TEE findings prompted surgical resection of the papillary muscle. This case demonstrates the importance of TEE guidance when inserting an LVAD cannula and in the subsequent reevaluation of patients with mechanical circulatory assist devices, and reminds us that obstructing papillary muscles must be considered in the differential diagnosis of LVAD dysfunction.
Figure 1: Anterior papillary muscle (arrow) obstructing the left ventricular inflow cannula of a continuous-flow extracorporeal CentriMag left ventricular assist system (Levitronix LLC, Waltham, MA, USA)
Figure 2: Continuous wave Doppler demonstrating significantly elevated peak inflow velocities with intermittent obstruction corresponding with papillary muscle prolapse. Normal peak inflow velocities for continuous-flow left ventricular assist devices range 1–2 m/s[1]
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Website: www.annals.in PMID: *** DOI: 10.4103/0971-9784.97986 Quick Response Code:
Address for correspondence: Dr. Steven T Morozowich, Department of Anesthesiology, Section of Cardiothoracic Anesthesia, Mayo Clinic College of Medicine, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA. E-mail:
[email protected]
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Annals of Cardiac Anaesthesia Vol. 15:3 Jul-Sep-2012
[Downloaded free from http://www.annals.in on Thursday, July 19, 2012, IP: 125.16.60.178] || Click here to download free Android application for this journal Humpherys, et al.: Papillary muscle obstruction of left ventricular assist device
REFERENCES 1. Chumnanvej S, Wood MJ, MacGillivray TE, Melo MF. Perioperative echocardiographic examination for ventricular assist device implantation. Anesth Analg 2007;105:583-601. 2. Augoustides JG. Perioperative echocardiographic assessment of the left ventricular assist device implantation: additional causes of inflow cannula obstruction. Anesth Analg 2008;106:673-4; author reply 674. 3. Oda N, Kato TS, Niwaya K, Komamura K. Unusual cause of left ventricular assist device failure: pendulating mass in the cavity. Eur J Cardiothorac
Surg 2007;32:533. 4. Horton SC, Khodaverdian R, Chatelain P, McIntosh ML, Horne BD, Muhlestein JB, et al. Left ventricular assist device malfunction: An approach to diagnosis by echocardiography. J Am Coll Cardiol 2005;45:1435-40. Cite this article as: Humpherys CG, Morozowich ST, Ramakrishna H. Intermittent obstruction of left ventricular assist device due to prolapsing papillary muscle. Ann Card Anaesth 2012;15:250-1. Source of Support: Nil, Conflict of Interest: None declared.
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