Concomitant aortic valve procedures in patients undergoing implantation of continuous-flow left ventricular assist devices: An INTERMACS database analysis

Abstract

Background Management of existing aortic insufficiency (AI) and mechanical aortic valves in patients undergoing left ventricular assist device (LVAD) implantation remains controversial. Surgical options to address these issues include closure, repair or replacement of the valve. Methods Continuous flow LVAD/BiVAD patients entered into the INTERMACS database between June 2006 to December 2012 were included (n=5,344). Outcomes were compared between patients who underwent aortic valve (AV) closure (n=125), repair (n=95) and replacement (n=85). Results Among patients that underwent an aortic valve procedure, actuarial survival was significantly reduced for AV closures (63.2%) compared to AV repairs (76.8%) and replacements (71.8%, p=0.0003). Differences were greater between groups when only INTERMACS level 1-2 patients were analyzed (p=0.003). After multivariate adjustment, aortic valve closure remained a significant risk factor for mortality (HR=1.87, 95% CI=1.39-2.53, p<0.0001). At six to twelve months postoperatively, moderate to severe AI developed in 19%, 5%, 9% and 10% of patients with available echocardiography who underwent repair, closure, replacement and no intervention, respectively (p<0.0001). Competing outcomes demonstrate that at 1-year fewer patients with aortic valve closures were transplanted compared to patients with repairs/replacements (14% vs. 19%). No differences were observed between groups with respect to cause of death, re-hospitalization, right heart failure or stroke. Conclusions AV closure was associated with increased mortality when compared to repair or replacement in patients with AI that underwent LVAD insertion. The reasons for this association require further investigation. This is the largest study to date to examine concomitant AV procedures in patients undergoing LVAD insertion.

Hemodynamic Effects of Concomitant Mitral Valve Surgery and Left Ventricular Assist Device Implantation

“…For example, preoperative aortic valve regurgitation can deteriorate after LVAD implantation and concomitant aortic valve procedures are established strategy to avoid this complication. [3][4][5] However, there are conflicting data regarding the benefit of mitral valve (MV) procedures concomitant to LVAD implantation for patients with preoperative significant mitral regurgitation (MR).…”

Outcomes After Concomitant Procedures with Left Ventricular Assist Device Implantation: Implications by Device Type and Indication

“…Recent evidence suggests that aortic valve closure is associated with increased early mortality when compared with aortic valve repair or replacement. 22 Our patient cohort with LVAV + AV may be a selected group with better early outcomes and could explain comparable perioperative mortality. The effect of a central aortic repair with CF-LVAD on longterm (greater than 2 years) valve function, risk of thrombus formation, and residual valve insufficiency remains unclear.…”

Echocardiographic evaluation of ‘sandwich plug’ closure of mechanical aortic valve at left ventricular assist device implantation

“…For the patient with a mechanical aortic valve who requires LVAD placement, there is debate as to the best approach as, unlike biological valves, mechanical valves cannot be easily closed. Some surgeons recommend replacement with a biological valve; however, this adds complexity to the procedure, worsens outcomes and may not completely reduce the risk of thromboembolism 2. Others advocate for placement of an autologous pericardial patch covering the mechanical valve.…”

“…The occluder is created prior to bypass limiting bypass and cross-clamp times which are lengthier when using a pericardial patch which must be sewn into place 2. Due to the complexity of the occluder, potential disadvantages include a risk of mechanical failure of the device or movement of the occluder on the valve, though no failures have been described at our centre or by the original developers of the technique 3.…”