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Left ventricular assist device malfunction: a systematic approach to diagnosis

Steven C. Horton, MD, FACC^,*, Reza Khodaverdian, MD^*, Amanda Powers, BS, James Revenaugh, MD, FACC, Dale G. Renlund, MD, FACC, Stephanie A. Moore, MD, FACC^*, Brad Rasmusson, MD^*, Karl E. Nelson, BS, MBA and James W. Long, MD, PhD^*

^* Division of Utah Artificial Heart ProgramSalt Lake City, Utah, USA
Department of Cardiology, LDS HospitalSalt Lake City, Utah, USA
University of Utah School of Medicine, Salt Lake City, Utah, USA

View larger version (63K): [in a new window]   Figure 1 Normal HeartMate left ventricular assist device (LVAD) physiology. The Thoratec HeartMate LVAD commences support at the left ventricular apex where a cannula allows blood to flow across a 25-mm Medtronic pig valve into the LVAD pumping chamber. An electric motor moves a cam 360°, which engages and raises a pusher plate. This movement ejects a systolic volume of 80 cc. Blood is ejected across a second 25-mm Medtronic pig valve through an outflow graft that has an anastamosis in the proximal ascending aorta. Synchronous pumping means LVAD systole occurs simultaneously with native left ventricular systole. Asynchronous pumping indicates the LVAD ejects during native left ventricular diastole.

View larger version (68K): [in a new window]   Figure 5 Examples of inflow valve regurgitation. (A) Left ventricular opacification. (B) Hemodynamic data. Ao = aorta; CO = cardiac output; ECG = electrocardiogram; LVAD = left ventricular assist device; PA = pulmonary artery; PCW = pulmonary capillary wedge; RA = right atrial pressure. (C) Appearance of inflow valve at time of surgery.

View larger version (58K): [in a new window]   Figure 6 Examples of a kinked outflow graft. (A) High pressures measured within the left ventricular assist device pumping chamber, with simultaneous aortic pressures. (B) Angiographic appearance.

View larger version (109K): [in a new window]   Figure 7 Example of normal aortic pressure with left ventricular assist device support during ventricular fibrillation. AO = aorta.

View larger version (90K): [in a new window]   Figure 8 (A) Normal sinus rhythm on entry to the catheterization laboratory. (B) Electrocardiogram with electrical artifact with exchange wire across the inflow valve.

View larger version (142K): [in a new window]   Figure 2 Angiography of the outflow graft.

View larger version (100K): [in a new window]   Figure 3 Aortic blood pressure variability with simultaneous left ventricle (LV) tracing in a patient with left ventricular assist device (LVAD) inflow valve regurgitation. ART = arterial pressure.

View larger version (76K): [in a new window]   Figure 4 Inflow valve regurgitation (IVR) waveforms. Pressure tracing taken from the left ventricle (LV) in the presence of severe IVR during periods of asynchronous and synchronous pumping. Arrows indicate IVR waves associated with regurgitation from the left ventricular assist device (LVAD) into the LV when the LVAD ejects. Other abbreviations same as in Figure 3.