First Successful Management of Aortic Valve Insufficiency Associated With HeartMate II Left Ventricular Assist Device Support by Transfemoral CoreValve Implantation

Abstract

Left ventricular assist device (LVAD) support has offered many individuals with end-stage heart failure an improved quality of life and enhanced survival. Prolonged mechanical assistance, however, has shown the potential to induce hemodynamic and structural changes in the native heart. One such dismal drawback is the development of de novo aortic valve lesions leading to aortic insufficiency (AI). Significant AI can lead to ineffective LVAD output and end-organ malperfusion, and may hamper the success of recovery attempts. If AI at the time of LVAD implantation can be proactively managed by replacement or closure of the aortic valve, later development of aortic valve dysfunction may pose a difficult management issue.A 53-year-old male patient (height, 190 cm; weight, 90 kg) with end-stage dilated cardiomyopathy was uneventfully implanted with a Thoratec HeartMate II LVAD (Thoratec Corporation, Pleasanton, California) intended as a bridge to transplantation. Ten months postoperatively, he showed progressively worsening AI requiring hospital readmissions for increased exercise intolerance, desaturation, and arrhythmias. In view of the unfavorable anthropometric characteristics, any attempt to anticipate transplantation was unsuccessful for lack of appropriate donors. Ineffective LVAD output, pulmonary edema with desaturation, and arrhythmias ultimately required endotracheal intubation and cardiopulmonary resuscitation. Since neither optimal medical therapy nor LVAD adjustments provided hemodynamic stability, the heart team decided for emergency life-saving aortic valve implantation (Fig. 1, Online Video 1). Transcatheter aortic valve implantation was undertaken with a percutaneous approach through the right femoral artery. Through an 18-F introducer, an extra-stiff guidewire was positioned in the left ventricle, and a 29-mm CoreValve (Medtronic, Milwaukee, Wisconsin) was implanted under fluoroscopy and echo control. Due to a moderate periprosthetic regurgitation (Fig. 2, Online Video 2), a second 29-mm CoreValve was deployed within the previous valve prosthesis From the

First report of a simultaneous transcatheter mitral valve‐in‐valve and aortic valve replacement in a left ventricular assist device patient

“…After transcatheter mitral valve replacement, we proceeded with transcatheter aortic valve replacement. This has been previously described in patients with left ventricular assist devices, and we faced similar challenges as others have outlined . In particular, most LVAD patients develop aortic insufficiency because of aortic leaflet retraction and remodeling, without calcification of the annulus.…”

“…Right heart catheterization revealed significant elevation of right sided pressures (CVP 24, PA 70/33, PCWP 30) and diminished cardiac index (1.9 L/min/m 2 ) despite normal LVAD function. Our team considered her high surgical risk, and we decided to perform mitral valve‐in‐valve implantation via transseptal route, followed by transfemoral aortic valve replacement, given the feasibility of each approach previously demonstrated .…”

Percutaneous closure of the aortic valve as a bridge to heart transplantation to treat severe aortic insufficiency after ventricular assist device

“…Furthermore, the patient with a completely closed AV is significantly more vulnerable to a catastrophic outcome in the event of LVAD mechanical failure or thrombosis. Alternatives such as transcatheter AV replacement (TAVR) for treating severe de novo AI have been described but with even fewer cases . As TAVR was originally designed for patients with severely calcified AVs and severe AV stenosis, there are reasonable concerns that the implanted TAVR valve could migrate antegrade or even retrograde into the left ventricle near the inlet, due to the increased diastolic flow in the aortic root propelled by the LVAD .…”

Medical Management of Patients With Continuous-Flow Left Ventricular Assist Devices

“…The combination of this high pressure gradient between the aorta and the decompressed LV on an LVAD and continuous blood flow explains, in part, why a small regurgitant orifice can lead to a large volume of regurgitant blood flow. Percutaneous closures of the AV [75–78] and transcatheter aortic valve replacements [79,80] have been reported for the management of AI, though long-term data are limited. In select cases, some patients also require surgical intervention for AV replacement or LV outflow tract closure by suturing closed the AV.…”