Successful Long-Term Outflow Graft Patency Restoration With a Stent-Graft Implantation in an LVAD Recipient (JACC Case Reports January 2026)-Article: Successful Long-Term Outflow Graft Patency Restoration With a Stent-Graft Implantation in an LVAD Recipient

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This case report describes a 70-year-old man with advanced ischemic heart failure who had been supported for 2.5 years with a HeartMate 3 left ventricular assist device (LVAD) and an outflow graft (OG) antitwist clip. After hospitalization for driveline infection, he developed worsening dyspnea, peripheral edema, and increasingly frequent low-flow LVAD alarms despite infection improvement and optimized volume status. Initial ECG and echocardiography were unrevealing, but repeat echocardiography showed left ventricular dilation, a continuously opening aortic valve, and turbulent high-velocity flow in the proximal OG (peak velocity 3.0 m/s; gradient 36 mm Hg), raising suspicion for OG obstruction.<br /><br />CT angiography confirmed significant proximal OG narrowing with discrete twisting and a circumferential wall-adherent thrombus. Because of major comorbidities and high surgical risk, the heart team declined urgent transplant and surgical graft exchange, opting for percutaneous treatment. Anticoagulation was intensified (warfarin target INR 2.0–3.0, bridging heparin/enoxaparin) plus clopidogrel due to aspirin resistance.<br /><br />In a hybrid operating room, a multispecialty team performed OG intervention using brachial access with bilateral carotid neuroprotection (Sentinel) and therapeutic heparinization to reduce stroke risk. A balloon-expandable stent-graft was deployed in the proximal OG, initially restoring LVAD flow (to ~4.0 L/min) and relieving symptoms. Shortly afterward, LVAD flow abruptly collapsed due to a new critical narrowing at the very proximal OG, likely from “translocation” of the stenosis (and a twist component). This was successfully treated with balloon angioplasty, restoring normal flow without pump stoppage. Small thrombi were captured in the neuroprotection device. A bleeding complication at the access site required surgical revision.<br /><br />The patient was discharged in NYHA class II with improved LVAD flows (~4.8 L/min) and remained stable for 2.5 years (flow 4.5–5.0 L/min). The report highlights that OG obstruction can be multifactorial and clinically subtle, often requiring multimodality imaging and complex percutaneous management; stent-grafting with adjunct ballooning may provide durable long-term results.

Meta Tag

Concept Outflow Graft Obstruction

Concept Left Ventricular Assist Device

Concept Cardiac Ultrasound

Concept Contrast CT

Concept Low-Flow Alarm

Keywords

HeartMate 3

left ventricular assist device

LVAD low-flow alarms

outflow graft obstruction

outflow graft twisting

outflow graft thrombus

CT angiography

percutaneous stent-graft

balloon angioplasty

carotid neuroprotection (Sentinel)

Outflow Graft Obstruction

Left Ventricular Assist Device

Cardiac Ultrasound

Contrast CT

Low-Flow Alarm