Cardiac Tamponade from Biodebris Accumulation in Long Term HVAD Support

Introduction As patients live longer on mechanical circulatory support (MCS), it is crucial to recognize long term device complications. We present a case of an unusual late complication after an HVAD implantation. Case Report A 51 year old female implanted with HVAD 6.5 years ago as a bridge to transplant presented with hypotension and UTI. She received IV fluids and antibiotics, and antihypertensive medications were held with clinical improvement. Surveillance RHC showed high filling pressures (RA 25 mmHg, Wedge 38 mmHg) and low cardiac index (1.8 mL/kg/m2). After diuresis, she developed acute hypotension, low flows and a pulsatility waveform consistent with suction for which device speed was decreased. Despite volume resuscitation she had PEA arrest requiring CPR and inotrope support. An echocardiogram showed near complete compression of the RA and RV by a fluid collection adjacent to the outflow tract. An emergent CT showed a 5.2 × 8.4 × 9.7 cm fluid collection around the outflow graft, extending from the proximal conduit to the aortic anastomosis. There was mass effect causing effacement of the IVC-RA junction and compression of SVC consistent with tamponade. The outflow graft was patent without signs of compression. Due to concern for bleeding from the graft, the patient was taken to surgery. Intraoperatively, there was a large amount of gelatinous material within the Gore-Tex wrapping of the conduit and no bleeding. The biodebris was evacuated with immediate relief of cardiac compression. Gore-Tex membranes were removed, and the chest was closed. The patient recovered and is doing well. Summary We present the first case of biodebris within Gore-Tex outflow graft wrapping causing cardiac tamponade. Gore-Tex wrapping of MCS devices is used to facilitate future explanting but may cause accumulation of biodebris over time. The phenomenon was previously described with HeartMate devices owing to the design of the bend relief resulting in outflow graft compression, but is unusual for HVAD devices, and has not been reported to cause tamponade.