Diagnosis of LVAD Thrombus using a High-Avidity Fibrin-Specific 99mTc Probe

Treatment of advanced heart failure with implantable LVADs is increasing, driven by profound unmet patient need despite potential serious complications: bleeding, infection, and thrombus. The experimental objective was to develop a sensitive imaging approach to assess early thrombus accumulation in LVADs under operational high flow and high shear rates. Methods: A monomeric bifunctional ligand with a fibrin-specific peptide, a short spacer, and Tc-99m chelating amino acid sequence (F1A) was developed and compared to its tetrameric PEG analogue (F4A). Results: Tc-99m attenuation by LVAD titanium (1 mm) was 23%. Tc-99m-F1A affinity to fibrin was K-d similar to 10 mu M, whereas, the bound Tc-99m-F4A probe was not displaced by F1A (120,000:1). Human plasma interfered with Tc-99m-F1A binding to fibrin clot (p<0.05) in vitro, whereas, Tc-99m-F4A targeting was unaffected. The pharmacokinetic half-life of Tc-99m-F4A was 28% faster (124 +/- 41 min) than Tc-99m-F1A (176 +/- 26 min) with both being bioeliminated through the urinary system with negligible liver or spleen biodistribution. In mice with carotid thrombus, Tc-99m-F4A binding to the injured carotid was much greater (16.3 +/- 3.3 % ID/g, p=0.01) than that measured with an irrelevant negative control, Tc-99m-I4A (3.4 +/- 1.6 % ID/g). In an LVAD mock flow-loop (1:1, PBS:human plasma: heparin) operating at maximal flow rate, Tc-99m-F4A bound well to phantom clots in 2 min (p<0.05), whereas Tc-99m-F1A had negligible targeting. Excised LVADs from patients undergoing pump exchange or heart transplant were rewired, studied in the mock flow loop, and found to have spatially variable fibrin accumulations in the inlet and outlet cannulas and bearings. Conclusions: Tc-99m-F4A is a high-avidity prototype probe for characterizing thrombus in LVADs that is anticipated to help optimize anticoagulation, reduce thromboembolic events, and minimize pump exchange.