Abstract
Background
Left ventricular assist devices (LVADs) have become a cornerstone in the management of advanced heart failure. However, they are also associated with a range of complications, among which the development of an aortic root thrombus is particularly serious.
Case Summary
A 72-year-old man developed refractory ventricular arrhythmias shortly after implantation of a HeartMate 3 LVAD, and he was found to have an aortic root thrombus extending into the left main artery. Given his high surgical risk, we performed to our knowledge the first documented percutaneous aspiration thrombectomy of the aortic root thrombus, leading to resolution and clinical recovery.
Discussion
This case underscores the importance of early recognition and highlights a novel approach to managing aortic root thrombi in LVAD patients.
Take-Home Messages
Early recognition of aortic root thrombi is critical. Percutaneous aspiration thrombectomy is a viable, innovative option for select LVAD patients at high surgical risk.
Key words: complications, coronary obstruction, durable mechanical support, left ventricular assist device, percutaneous aspiration thrombectomy
Visual Summary
History of Presentation
A 72-year-old man with a history of chronic ischemic cardiomyopathy presented with worsening shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and edema—symptoms consistent with decompensated heart failure. Notably, he had experienced numerous hospitalizations for similar episodes in the preceding months. While he responded to treatment, he underwent evaluation for advanced heart failure therapies during his admission. Given his age and comorbidities, he was not considered a suitable candidate for heart transplantation. However, after a thorough multidisciplinary assessment, he was deemed eligible for HeartMate 3 left ventricular assist device (LVAD) (Abbott) implantation, which he successfully underwent. The patient exited the operating room with an LVAD speed of 4,800 RPM. Within 24 hours, the speed was increased to 5,000 RPM, at which point it was maintained. On postoperative day 2, he was appropriately initiated on anticoagulation with heparin and coumadin per our institutional protocol. However, on postoperative day 5, he developed recurrent episodes of ventricular tachycardia (VT) and ventricular fibrillation (VF) that proved refractory to multiple antiarrhythmic therapies, ultimately requiring intubation and sedation.
Past Medical History
The patient had a history of ischemic cardiomyopathy with an ejection fraction of <20%, biventricular implantable cardioverter-defibrillator placement, coronary artery disease with previous percutaneous coronary interventions, chronic kidney disease, and abdominal aortic aneurysm after having undergone endovascular aortic repair.
Differential Diagnosis
The differential diagnosis of this patient's ventricular arrhythmias included several factors related to both preexisting and procedure-induced changes. Myocardial scarring from prior cardiac events or structural disease may have contributed to arrhythmogenic substrates. Electrical remodeling after LVAD implantation could have altered conduction pathways, as well as mechanical irritation from the inflow cannula or suction events due to inadequate preload. Additionally, inotropic medications and heightened sympathetic nervous system activity could have exacerbated arrhythmogenic potential. Other critical considerations included acute myocardial infarction or aortic dissection with coronary artery involvement.
Investigations
Considering his refractory ventricular arrhythmias, the patient underwent a coronary angiogram, which revealed a concerning occlusion and absence of flow within the left main coronary artery (LMCA). This was characterized by a significant filling defect within the left coronary cusp (Figure 1, Video 1), raising suspicion for a potential aortic dissection. To further evaluate this finding, transesophageal echocardiography (TEE) was promptly performed, which instead identified a large thrombus within the left coronary cusp extending into the LMCA (Figure 2, Video 2). The TEE provided crucial insight into the size and precise location of the thrombus, confirming its consequential significance. Given the severity of the obstruction and the strong likelihood that the thrombus was the underlying trigger for the patient's recurrent arrhythmias, an immediate intervention was deemed necessary.
Figure 1.
Findings on Coronary Angiography
Coronary angiography of the (A) right coronary system and (B) left coronary system. There is absence of flow within the left main coronary artery. (C) An aortogram demonstrated a significant filling defect within the left coronary cusp (arrow).
Figure 2.
TEE of the Aortic Root With Evidence of a Large Thrombus
The thrombus was seen within the left coronary cusp and extended into the LMCA (arrows). LMCA = left main coronary artery; TEE = transesophageal echocardiography.
Management
Initial management was attempted with systemic thrombolysis with intravenous tissue plasminogen activator, as an attempt to treat the thrombus and alleviate the arrhythmias; however repeat TEE at 24 hours and subsequently at 48 hours did not show any improvement in thrombus size. Despite therapeutic anticoagulation, the patient continued to experience a high burden of ventricular arrhythmias, indicating persistent thrombotic occlusion of the LMCA. Considering the patient's overall clinical status with lack of response to thrombolysis, his elevated surgical risk, and the goal of avoiding a high-risk redo sternotomy, a multidisciplinary heart team discussion determined an approach with percutaneous aspiration thrombectomy as the most feasible and least invasive intervention.
To mitigate the risk of cerebral embolic events during the procedure, a Sentinel cerebral protection system (Boston Scientific) was deployed via the right radial artery. Access was then obtained through the right common femoral artery, where a 16-F DrySeal sheath (Gore Medical) was introduced. Using the Penumbra Lightning Flash 2.0 computer-assisted vacuum thrombectomy catheter (Penumbra Inc), the device was advanced to the aortic root, and aspiration was performed within the left coronary cusp, successfully removing a significant portion of the thrombus (Figure 3, Video 3). Intraprocedural TEE demonstrated successful resolution of the thrombus within the aortic root; however, follow-up angiogram revealed persistent large thrombus burden within the LMCA, extending in the left anterior descending artery (Figure 4, Video 4) and necessitating further intervention.
Figure 3.
Aspiration of the Thrombus With the Penumbra Device
The Penumbra Lightning Flash 2.0 computer-assisted vacuum thrombectomy catheter (arrow) was advanced to the aortic root, and aspiration of the thrombus was performed within the left coronary cusp.
Figure 4.
Follow-Up Angiography and Intraprocedural TEE
(A) Follow-up angiogram revealed persistent large thrombus burden within the LMCA, extending in the left anterior descending artery. (B) Intraprocedural TEE demonstrated successful resolution of the thrombus within the aortic root; however, there was remaining thrombus in the ostium of the LMCA (arrows). LMCA = left main coronary artery; TEE = transesophageal echocardiography.
In response to the persistent thrombus, a Penumbra Bolt 7 thrombectomy device (Penumbra Inc) was connected to an EBU 3.5 guide catheter, facilitating access and precise navigation. A GuideLiner guide extender (Teleflex) was then advanced beyond the catheter into the LMCA, allowing for controlled aspiration and effective extension within the vessel (Figure 5, Video 5). Additional aspiration was performed, leading to the complete resolution of the thrombus, and TIMI flow grade 3 was restored, as confirmed by repeat angiography (Figure 6, Video 6). TEE further confirmed the resolution of the thrombus at the ostium of the LMCA (Figure 7, Video 7). Importantly, TEE additionally revealed no residual damage to the aortic valve, with only trivial aortic regurgitation, which had been present before LVAD implantation. Finally, the Sentinel cerebral protection device was retrieved, showing successful capture of small, fragmented clot material during the aspiration procedure (Figure 8).
Figure 5.
Use of Penumbra Bolt 7 Device in Response to the Persistent Thrombus
The Penumbra Bolt 7 thrombectomy device was connected to an EBU 3.5 guide catheter, and a GuideLiner guide extender was then advanced beyond the catheter into the LMCA, allowing for controlled aspiration and effective extension within the vessel. LMCA = left main coronary artery.
Figure 6.
Final Coronary Angiography Demonstrating Restoration of TIMI Flow Grade 3 Within the Left Coronary System and Resolution of Thrombus Burden
Figure 7.
Final TEE Demonstrating Resolution of Thrombus Burden Within the Ostium of the LMCA (Arrow)
LMCA = left main coronary artery; TEE = transesophageal echocardiography.
Figure 8.
Retrieval of the Sentinel Device
(A) Retrieval of the Sentinel cerebral protection device showing successful capture of small, fragmented clot material during the aspiration procedure. (B) The Penumbra canister demonstrating the clot burden that was removed. (C) The gross specimen of thrombus that was removed during the procedure.
Outcome and Follow-Up
The patient demonstrated significant clinical improvement after the intervention. His hemodynamic stability was restored, and the frequency of VT and VF episodes significantly decreased. Importantly, he remained neurologically intact, with no evidence of deficits postprocedure. However, despite the reduction in arrhythmia burden, he continued to experience nonsustained VT, ultimately requiring a robotic-assisted bilateral thoracoscopic sympathectomy for definitive management. His condition improved, and he was discharged to a long-term care facility for continued rehabilitation and medical optimization. Over time, he has shown gradual progress and remains under close follow-up in the heart failure clinic, where his condition continues to advance.
Discussion
Continuous-flow LVADs have become an integral component of advanced heart failure management, serving as both a bridge to heart transplantation and a long-term destination therapy.1 While LVADs significantly improve hemodynamics, provide symptom relief, and enhance quality of life in end-stage heart failure, they are also associated with a range of complications.2 Common postimplantation complications include bleeding, right heart failure, infection, pump thrombosis, and arrhythmias.3,4 Although rare, aortic root thrombus formation is a particularly severe complication that can precipitate ischemic coronary events, life-threatening arrhythmias, and cerebrovascular embolism, contributing to increased morbidity and mortality.5,6 The underlying pathophysiology of thrombus formation in this setting is multifactorial, involving altered hemodynamics, turbulent flow, and stasis within the aortic root, particularly in patients with pre-existing cardiovascular disease.7 Prior studies indicate that these thrombi typically develop in the early postoperative period, with a higher incidence in patients with right ventricular failure, persistently closed aortic valves, and those implanted under a destination therapy strategy.5
Given the lack of established guidelines for managing aortic root thrombi in LVAD recipients, therapeutic approaches remain largely empirical. Systemic anticoagulation is considered the first-line treatment, however, in cases of persistent thrombus burden and hemodynamic instability, more aggressive interventions may be required. Although systemic thrombolysis has been reported in select situations, its use early after LVAD implantation carries a substantial risk of major bleeding, and therefore such decisions must be individualized and undertaken only after careful multidisciplinary evaluation. In our case, conventional and noninvasive management failed to resolve the thrombus, necessitating an innovative, catheter-based approach. This case details to our knowledge the first-ever documented TEE- and fluoroscopy-guided mechanical aspiration thrombectomy of an aortic root and LMCA thrombus that developed acutely, post-LVAD implantation, using Penumbra thrombectomy devices. The procedure led to complete thrombus resolution, termination of the patient's refractory arrhythmias, and overall clinical recovery, demonstrating the feasibility and effectiveness of percutaneous intervention in select high-risk cases. This case highlights the critical role of a multidisciplinary heart team in managing complex LVAD-related complications, ensuring individualized and timely therapeutic decision-making. Furthermore, it underscores the advancements in interventional cardiology that are expanding the treatment options for patients with LVAD-related thrombotic events.
Conclusions
As the use of LVADs continues to rise, recognizing and addressing their potential complications is paramount to optimizing patient outcomes and long-term success. This case not only illustrates a novel percutaneous approach to an otherwise high-risk complication but also paves the way for future advancements in management strategies for acute aortic root thrombi in LVAD patients. Vigilant monitoring and continued innovation in interventional techniques will be essential in improving care for this growing patient population.
Funding Support and Author Disclosures
Dr Thomas has received consulting fees, honoraria, and/or speaker fees from Boston Scientific and Philips. Dr Sayfo has received consulting fees, honoraria, and/or speaker fees from AngioDynamics, Medtronic, Inari Medical, Penumbra, Philips, Boston Scientific, Terumo, and Surmodics. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Take-Home Messages
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Aortic root thrombi in LVAD patients carry a high risk of morbidity and mortality, making early recognition essential to prevent life-threatening complications such as ischemic coronary events and refractory arrhythmias.
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Percutaneous aspiration thrombectomy offers a promising, minimally invasive alternative for managing acute aortic root thrombi in LVAD patients, particularly those with elevated surgical risk.
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A multidisciplinary heart team approach is crucial in optimizing patient outcomes, ensuring timely diagnosis, individualized treatment strategies, and the integration of advanced interventional techniques.
Footnotes
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
Appendix
Visual Summary.
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Appendix
Findings on Coronary Angiography
Coronary angiography of the (A) right coronary system and (B) left coronary system. There is an absence of flow within the left main coronary artery. (C) An aortogram demonstrated a significant filling defect within the left coronary cusp.
TEE of the Aortic Root With Evidence of a Large Thrombus
The thrombus was seen within the left coronary cusp and extended into the left main coronary artery.
Aspiration of the Thrombus With the Penumbra Device
The Penumbra Lightning Flash 2.0 computer-assisted vacuum thrombectomy catheter was advanced to the aortic root, and aspiration of the thrombus was performed within the left coronary cusp.
Follow-Up Angiography and Intraprocedural TEE
(A) Follow-up angiogram revealed persistent large thrombus burden within the LMCA, extending in the left anterior descending artery. (B) Intraprocedural TEE demonstrated successful resolution of the thrombus within the aortic root; however, there was remaining thrombus in the ostium of the LMCA.
Use of Penumbra Bolt 7 Device in Response to the Persistent Thrombus
A Penumbra Bolt 7 thrombectomy device was connected to an EBU 3.5 guide catheter, and a GuideLiner guide extender was then advanced beyond the catheter into the LMCA, allowing for controlled aspiration and effective extension within the vessel.
Final Coronary Angiography Demonstrating Restoration of TIMI Flow Grade 3 Within the Left Coronary System and Resolution of Thrombus Burden
Final TEE Demonstrating Resolution of Thrombus Burden Within the Ostium of the LMCA
References
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Associated Data
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Supplementary Materials
Findings on Coronary Angiography
Coronary angiography of the (A) right coronary system and (B) left coronary system. There is an absence of flow within the left main coronary artery. (C) An aortogram demonstrated a significant filling defect within the left coronary cusp.
TEE of the Aortic Root With Evidence of a Large Thrombus
The thrombus was seen within the left coronary cusp and extended into the left main coronary artery.
Aspiration of the Thrombus With the Penumbra Device
The Penumbra Lightning Flash 2.0 computer-assisted vacuum thrombectomy catheter was advanced to the aortic root, and aspiration of the thrombus was performed within the left coronary cusp.
Follow-Up Angiography and Intraprocedural TEE
(A) Follow-up angiogram revealed persistent large thrombus burden within the LMCA, extending in the left anterior descending artery. (B) Intraprocedural TEE demonstrated successful resolution of the thrombus within the aortic root; however, there was remaining thrombus in the ostium of the LMCA.
Use of Penumbra Bolt 7 Device in Response to the Persistent Thrombus
A Penumbra Bolt 7 thrombectomy device was connected to an EBU 3.5 guide catheter, and a GuideLiner guide extender was then advanced beyond the catheter into the LMCA, allowing for controlled aspiration and effective extension within the vessel.
Final Coronary Angiography Demonstrating Restoration of TIMI Flow Grade 3 Within the Left Coronary System and Resolution of Thrombus Burden
Final TEE Demonstrating Resolution of Thrombus Burden Within the Ostium of the LMCA