Non-Stenotic, “Graft over Graft” LVAD Outflow Graft Protection Technique

• Published in: The Journal of heart and lung transplantation Vol. 39; no. 4; p. S442
• Main Authors: Nelson, T., Kawabori, M., Zhan, Y., Warner, K.G., Rastegar, H., Chen, F.Y., Kiernan, M.S., DeNofrio, D., Couper, G.S.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.04.2020
• ISSN: 1053-2498; 1557-3117
• DOI: 10.1016/j.healun.2020.01.254

Left ventricular assist devices (LVADs) are widely accepted for end-stage heart failure management. A traditional outflow graft (OFG) protection strategy using a polytetrafluoroethylene (PTFE) graft was developed in response to critical OFG injuries during redo full sternotomy. However, this graft fully covers the OFG and has been reported to cause stenosis from compression due to OFG exudate materials. This may cause increased afterload, low LVAD flow, and secondary left heart failure symptoms requiring additional procedures to relieve the stenosis. Therefore, a non-stenotic OFG protection technique is warranted. Here, we present our alternative “Graft over Graft” surgical technique for OFG protection that does not lead to OFG stenosis. The proper length of the OFG is adjusted and cut from the original length (a); the leftover piece of graft material is then used to cover the outflow graft. This excess graft is transected longitudinally to allow nesting of the graft (b,c). The transected excess material is wrapped around the outflow graft for protection (d), making the OFG more resilient during reentry in subsequent sternotomies (e). Because the posterior side of the graft remains open, no outflow graft exudate is found below the covering graft at the time of transplant (f), which minimizes risk of stenosis. We retrospectively analyzed our single-center experience. Our center has utilized both the traditional PTFE graft OFG cover, as well as the novel technique described. 51 patients at our center received the traditional PTFE graft cover, with 4 patients (7.8%) experiencing OFG stenosis requiring stent or surgical correction. 98 patients received the novel technique with none (0.0%) showing signs of graft stenosis, representing a significant difference (p=.002). This “Graft over Graft” OFG protection technique using original excess outflow graft is a safe, reproducible, and cost-effective method to reduce the risk of OFG stenosis and maintains protection during sternal reentry.