Managing Aortic Regurgitation and Dynamic Aortic Thrombus in a Patient With Left Ventricular Assist Device

Figures

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  Figure 1. Serial Computed Tomography Imaging After Durable Left Ventricular Assist Device Implantation Demonstrating Dynamic Changes in Wall-Adherent Thrombus Burden Within the Ascending Aorta

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  Figure 2. Computed Tomography Imaging of the Aortic Root and Ascending Aorta Demonstrating Wall-Adherent Thrombus (Blue) in Close Proximity to the Coronary Ostia and Measurements of the Aortic Annulus and LVOT (Red)

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  Figure 3. Balloon Occlusion of the Outflow-Graft That Is Anastomosed to the Descending Thoracic Aorta

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  Figure 4. Removed Thrombotic Material

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  Figure 5. Intraoperative Situs After Interventional Outflow-Graft Occlusion, Thrombus Removal, Aortic Cross-Clamping, and Excision of the Native Aortic Valve

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  Visual Summary. A Hybrid Strategy for Redo Surgical Aortic Valve Replacement A patient with a durable left ventricular assist device presented with severe aortic regurgitation (middle, transthoracic echocardiography). Procedural challenges included a mobile aortic thrombus (lower left, computed tomography), an enlarged aortic annulus (upper left, computed tomography), outflow graft anastomosis to the descending aorta, and adhesions from prior sternotomy. Management involved temporary balloon occlusion of the outflow graft (upper right, fluoroscopy), axillary cannulation, retrograde cardioplegia, and systemic cooling with a 3-minute circulatory arrest. This approach enabled safe thrombus extraction (lower right) and successful implantation of a bioprosthetic valve without neurological complications. CABG = coronary artery bypass grafting; TAVR = transcatheter aortic valve replacement.