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This article discusses the surgical treatment of postinfarction ventricular septal defect (VSD) and its high mortality rate. The study analyzed data from 46 patients treated at a single institution over a 10-year period. The primary endpoint of the study was 1-year survival, and the results showed a 50% survival rate for the whole group. The study suggests that beating-heart techniques should be considered to avoid additional myocardial ischemia. [Extracted from the article]

The HeartMate3 (HM3) left ventricular assist device (LVAD) has markedly improved hemocompatibility related adverse outcomes. In sporadic cases, external compression of the outflow graft causing obstruction (eOGO) can result from gelatinous substance accumulation between outflow graft and its bend relief covering. We sought to evaluate the prevalence, temporal course and clinical implications of eOGO with the HM3 LVAD in a global cohort study. A Multi-center retrospective analysis was conducted among 2014 HM3 LVAD patients across 16 cardiac centers in 8 countries (between 11/2014 and 4/2021). Presence of eOGO was defined as >25% of cross-sectional area identified by established imaging (percutaneous angiography, computed tomography or intravascular ultrasound). The prevalence and annual incidence were calculated. Serious adverse events and outcome (death, transplant or device exchange) at the end of the study were analyzed for those eOGO cases that required therapy versus those who were observed. Among 2014 patients, 61 patients were diagnosed with eOGO at a median LVAD support duration of 1024 [IQR: 636-1409] days. The overall prevalence of eOGO was at 3.0 %. The incidence at 1, 2, 3, 4, and 5 years on support was 0.6, 2.8, 4.1, 4.6 and 9.8 %. Of 52 patients, who required a therapeutic intervention, 26 underwent surgical revision, 16 patients were treated by percutaneous stent implantation, 8 underwent urgent heart transplantation and 2 died before intervention. In 9 patients a watchful waiting strategy without treatment was chosen. The mortality among those requiring therapeutic intervention was 9 of 52 (17.3%). This global multicenter cohort study suggests that while rare, HM3 LVAD supported patients may develop eOGO with an increasing incidence after 1 year on support. While targeted engineering efforts to alleviate this complication are underway by addressing early detection as well as outflow graft and bend relief design, clinicians must remain vigilant to this complication, especially in long-term survivors supported with the HM3 LVAD. [ABSTRACT FROM AUTHOR]

Reports of pump thrombosis are less common for the HeartMate 3 than for other commercially available LVAD. However, blood flow obstructions of the inflow and especially of the outflow graft are likely to occur also with this device. A correct diagnosis is crucial for optimal treatment to ultimately avoid bail-out by (urgent) heart transplantation or unwarranted pump exchange. We present six cases of outflow graft obstruction (OGO) other than twist of the outflow graft under oral anticoagulation. We present detection principles and discuss treatment strategies. 1: 64 y/o, female, valvular heart disease, 21 months after implantation, presentation with multiple low-flow alarms. 50% OGO in CT scan. External cannula compression proximal of the LVAD outflow conduit in percutaneous angiography (PA). Re-thoracotomy, opening of the bend relief made of a reinforced PTFE graft, removement of hyaline thrombus, pump flow returned to normal. 2: 70 y/o, female, dilated CMP, recurrent low-flow alarms, high PI values. Consistently low flow in ramp study. Treatment of severe OGO in PA with two stents. Pump flow returned to normal. 3: 55 y/o, male. Presentation of acute angina pectoris, dyspnea. 75% OGO in CT scan. PA and implantation of two stents. Relief from clinical symptoms. 4: 37 y/o male, dilated CMP. Routinely admission for evaluation for heart transplantation (HTx). LVAD log files normal. Significant OGO in CT scan. PA confirmed OGO, but no relevant gradient pressure across the outflow graft, decision to "watchful waiting approach" and listing for HTx. 5: 67 y/o, male, dilated CMP. Presentation in a reduced general condition and slightly reduced pump flow. 70% OGO in CT scan. Pump flow increased to normal after intervention. 6: 56 y/o, female, ischemic CMP. Presentation with acute persistent low-flow alarms. 50% OGO in CT scan. Multiple hypodense areas in the infra- and supratentorial region as consequence of an embolic induced ischemic stroke. Despite emergency treatment the patient died on the same day. OGO in LVAD is a rare complication whose clinical presentation may be subtle. Three patients were successfully managed with stents, one underwent surgical revision, one patient died despite emergency treatment and the last patient without symptoms was listed for HTx. [ABSTRACT FROM AUTHOR]