A routine intervention in a highly unusual vessel.

A 31-year-old woman with a HeartWareTM (Medtronic, Minneapolis, MN, USA) left ventricular assist device (LVAD), which had been implanted for ischaemic cardiomyopathy, presented with progressive dyspnoea. Bilateral pneumonia was suspected. Despite antibiotic treatment, the patient’s condition deteriorated: she became more dyspnoeic and developed cardiogenic shock with a low LVAD flow. Computed tomography angiography showed an intraluminal focal outflow graft stenosis. In a multidisciplinary team discussion, the patient was scheduled for an emergency percutaneous intervention via a femoral approach to avoid surgery, based on previous reports [1-3]. Angiography confirmed the stenosis, with an invasive peak-peak gradient of 80 mm Hg (Fig. 1a). This was treated with an Advanta V12 balloon-expandable covered stent (10 mm × 38 mm) and post-dilated with an Advance balloon (10 mm × 20 mm), resulting in a residual gradient of 10 mm Hg and an immediate increase in LVAD flow (Fig. 1b). The patient recovered uneventfully after this procedure.

Fig. 1

a Angiography confirming outflow graft stenosis (left panel, red arrow). Advanta V12 balloon-expandable covered stent (10 mm × 38 mm) in outflow tract (right panel, red arrow). b Invasive blood pressure monitoring demonstrating an 80-mm Hg gradient over the stenosis before the procedure (upper panel, red arrows) and a residual 10-mm Hg gradient after the procedure (lower panel, red arrows)

The incidence of outflow graft stenosis ranges from 0.01 to 0.03 per patient-year [4, 5]. Personalised anticoagulation protocols and surgical implantation techniques are currently being studied to prevent LVAD outflow graft obstruction due to stenosis, thrombosis or torsion.