A New Modification for Anastomosing HeartMate 3 Apical Cuff for a Small Left Ventricle

Introduction A preoperative small left ventricular size has been associated with higher mortality and complications after left ventricular assist device (LVAD) implantation. The small left ventricle (LV) may result in repeated suction events and inflow obstruction, possibly leading to pump thrombosis and malfunction and thromboembolism. The inflow cannula length of HeartMate 3 is 22 mm, and the CT-measured protrusion depth of inflow cannula into the LV was 13.5 ± 1.0 mm in our previous HeartMate 3 series (16 patients). Based on the concept that making the protrusion depth shallow should decrease the risk for suction event, we adopted a hand-made apical cuff, whose actual thickness was 6mm, modified by stacking three layers of felt on the original PTFE felt during HeartMate 3 implantation for a small LV patient. Here, we report two cases in which this modified apical cuff was used. Case Report One patient is a 47-year-old woman with idiopathic dilated cardiomyopathy who underwent implantation of a HeartMate 3. Preoperative echocardiography showed a small left ventricular end-diastolic dimension (LVDd) of 49 mm. We anastomosed the described-above modified apical cuff in a core then sew technique. Postoperative LVDd was 30 mm and cardiac index was 2.7 L/min/m2 under optimized pump setting. Another is a 58-year-old woman with dilated phase of hypertrophic cardiomyopathy who underwent implantation of a HeartMate 3. The preoperative LVDd of this patient was 48 mm. The same modified apical cuff was secured in a core then sew technique after resection of the intraventricular muscle through the apical coring hole. Postoperative LVDd was 37 mm and cardiac index was 2.2 L/min/m2 under optimized pump setting. Both patients experienced no significant suction event or adverse events and are still waiting for heart transplantation as an outpatient. Summary This modified apical cuff is promising for achieving adequate pump performance of HeartMate 3 and possibly improving the outcomes of LVAD therapy in patients with the small LV. A preoperative small left ventricular size has been associated with higher mortality and complications after left ventricular assist device (LVAD) implantation. The small left ventricle (LV) may result in repeated suction events and inflow obstruction, possibly leading to pump thrombosis and malfunction and thromboembolism. The inflow cannula length of HeartMate 3 is 22 mm, and the CT-measured protrusion depth of inflow cannula into the LV was 13.5 ± 1.0 mm in our previous HeartMate 3 series (16 patients). Based on the concept that making the protrusion depth shallow should decrease the risk for suction event, we adopted a hand-made apical cuff, whose actual thickness was 6mm, modified by stacking three layers of felt on the original PTFE felt during HeartMate 3 implantation for a small LV patient. Here, we report two cases in which this modified apical cuff was used. One patient is a 47-year-old woman with idiopathic dilated cardiomyopathy who underwent implantation of a HeartMate 3. Preoperative echocardiography showed a small left ventricular end-diastolic dimension (LVDd) of 49 mm. We anastomosed the described-above modified apical cuff in a core then sew technique. Postoperative LVDd was 30 mm and cardiac index was 2.7 L/min/m2 under optimized pump setting. Another is a 58-year-old woman with dilated phase of hypertrophic cardiomyopathy who underwent implantation of a HeartMate 3. The preoperative LVDd of this patient was 48 mm. The same modified apical cuff was secured in a core then sew technique after resection of the intraventricular muscle through the apical coring hole. Postoperative LVDd was 37 mm and cardiac index was 2.2 L/min/m2 under optimized pump setting. Both patients experienced no significant suction event or adverse events and are still waiting for heart transplantation as an outpatient. This modified apical cuff is promising for achieving adequate pump performance of HeartMate 3 and possibly improving the outcomes of LVAD therapy in patients with the small LV.