Less Frequent Opening of the Aortic Valve and a Continuous Flow Pump Are Risk Factors for Postoperative Onset of Aortic Insufficiency in Patients With a Left Ventricular Assist Device

Abstract

Background: Postoperative development of aortic insufficiency (AI) after implantation of left ventricular assist devices (LVADs) has recently been recognized, but the devices in the previous reports have been limited to the HeartMate I or II. The purposes of this study were to determine whether AI develops with other types of LVADs and to elucidate the factors associated with the development of AI. Methods and Results:Thirty-seven patients receiving LVADs without evident abnormalities in native aortic valves were enrolled (pulsatile flow LVAD [TOYOBO]: 76%, continuous flow LVAD [EVAHEART, DuraHeart, Jarvik2000, HeartMate II]: 24%). Frequency of aortic valve opening and grade of AI were evaluated by the most recent echocardiography during LVAD support. None of the patients had more than trace AI preoperatively. During LVAD support AI > -grade 2 developed in 9 patients (24%) across all 5 types of devices. More severe grade of AI correlated with higher plasma B-type natriuretic peptide concentration (r=0.53, P<0.01) and with less frequent of the aortic valve (r=−0.45, P<0.01). Multivariate analysis revealed that lower preoperative left ventricular ejection fraction and a continuous flow device type were independent risk factors for higher incidence of AI.Conclusions: AI, which is hemodynamically significant, develops after implantation of various types of LVADs. Physicians need to be more alert to the development of AI particularly with continuous flow devices. (Circ J 2011; 75: 1147 - 1155

Ventricular assist devices for heart failure: a focus on patient selection and complications

“…47,48 About 80% of patients without preoperative valve regurgitation showed rapid development of mild to moderate aortic regurgitation following their LVAD implantation. 49 This "de novo" aortic regurgitation induced by the LVAD is considered to have deleterious effects on pump efficiency and systemic output. In fact, this creates a circulatory loop of flow to the ventricle instead of the systemic circulation, diminishing the efficiency of support and the ventricular unloading.…”

“…Remarkably, in a small number of patients, the aortic regurgitation manifests only in the systolic phase of the cardiac cycle and probably would disappear at the opening of the aortic valve. 49,51 The mechanism involved in this LVAD-related systolic aortic regurgitation is still unknown, but may involve a different mechanism associated with dynamic modification of the aortic annulus or valve as a result of turbulence in the ascending aorta. However, when aortic regurgitation becomes more severe, valve repair may eventually be inevitable.…”

Concomitant Aortic Valve Procedures in Patients Undergoing Implantation of Continuous-Flow LVADs: An INTERMACS Database Analysis

“…Regurgitation through the aortic valve (AV) diminishes systemic perfusion, elevates left heart filling pressures and increases LVAD flow (1,2). This derangement is compounded by the progression of even minor aortic insufficiency with time on device support (2)(3)(4)(5)(6)(7)(8). Furthermore, existing mechanical aortic prostheses convey an increased risk for stroke from thromboembolism (2).…”

Preoperative Prediction of Aortic Insufficiency During Ventricular Assist Device Treatment

“…17) We also showed that AI was more frequently observed in patients with CF LVAD as compared with PF pump in 2011 ( Figure 1C). 18) Since then, a number of single-center studies have documented a wide-ranging prevalence of AI during LVAD treatment. 15,[19][20][21] The development of AI during LVAD treatment is considered to be a multifactorial phenomenon and a result of altered AV and aortic root biomechanics due to chronic and continuous ventricular unloading.…”

“…34) Native AV can be replaced with a bioprosthetic valve, but newly placed biologic valves are still at risk for the development of postoperative AI. 18) Park, et al first reported a simple technique of concomitant AV repair at the time of LVAD implantation (Park's stitch), 35,36) but the repair also carries a risk for recurrence of AI. Patch closure of the outflow tract is another strategy.…”