Percutaneous Transcatheter Interventions for Aortic Insufficiency in Continuous-Flow Left Ventricular Assist Device Patients: A Systematic Review and Meta-Analysis

Abstract

De novo progressive aortic insufficiency (AI) is a side effect frequently related to prolonged support with continuous-flow left ventricular assist devices (CF-LVAD). Its progression can result in recurrent clinical heart failure symptoms and significantly increased mortality. Recently, percutaneous intervention methods, such as transcatheter aortic valve replacement (TAVR) and percutaneous occluder devices, have emerged. However, given the very scarce global experience with these approaches, evidence in the literature is lacking. We sought to assess the outcomes of CF-LVAD patients who had undergone percutaneous intervention for AI. A systematic search of six databases from inception to April 2016 was performed by two independent reviewers. Eligible studies were those that included series or cases where patients had percutaneous transcatheter interventions for AI in CF-LVAD patients. Data were extracted and meta-analyzed from the identified studies. A total of 29 patients from 15 published studies and 3 unpublished records were included in the analysis. Mean patient age was 56.6 ± 13.7 years, and 72.4% were male. The etiology of heart failure resulting in LVAD placement was ischemic cardiomyopathy in 17.2%. The two intervention groups were TAVR (27.6%) and occluder devices (72.4%). A transfemoral approach (69%), apical approach (10%), brachial approach (7%), subclavian approach (3%), and mini-sternotomy (3%) were used. The preintervention AI grade was severe with a median grade of 4 (interquartile range, 4-4). Postoperatively, the AI grade improved significantly to a median grade of 0 (0-2). At long-term follow-up AI grade was still trivial with a median AI grade of 1 (0-1). Subgrouping the treatments into the occluder device and TAVR, it was found that both interventional techniques were similarly effective in reducing the AI grade from severe to trivial. In terms of complications, from the occluder group, two patients were complicated with device migration and another two with transient hemolysis. In the TAVR cohort, two patients experienced device migration and another had significant postimplant perivalvular leakage. Our results indicate that percutaneous interventions for AI in CF-LVAD patients with TAVR, and closure devices demonstrate similar efficacy in significantly reducing severe AI. Current results are encouraging, potentiating viability as a treatment option, particularly in nonsurgical candidates. Future research with larger patient cohorts and comparative controls is required to sufficiently evaluate the efficacy of this technique and promote its widespread acceptance as a mainstay treatment.

Transfemoral aortic valve replacement for severe aortic valve regurgitation in a patient with a pulsatile‐flow biventricular assist device

“…10 A major advantage of TAVR compared with occluder devices is that patients are not fully dependent on the VAD, as it does not completely unload the left ventricle by occluding either the aortic valve or left ventricular outflow tract. Experience with Edwards SAPIEN 3, Medtronic CoreValve, Medtronic Evolut R, and Medtronic Melody has been described.…”

“…[4][5][6] Compared with PF-VADs, CF-VADs feature improved reliability, durability, and survival, but the diminished pulsatility is considered to be responsible for some complications: gastrointestinal bleeding, pump thrombosis, and aortic regurgitation (AR). 10,11 However, there is a very scarce experience of TAVR in this setting of patients, mainly focused on CF-VAD technology. 8 Aortic regurgitation in patients with VADs represents a medical challenge, and to date, there are no consensual C A S E R E P O R T recommendations regarding treatment strategies of VADassociated AR, varying from medical therapy, and optimizing VAD-pump speed, to minimal invasive and surgical treatment options.…”

“…5,7 However, AR is also seen in patients implanted with pulsatile-flow biventricular assist devices (PF-BiVADs), which are used in selected patients with severe biventricular heart failure as bridge-to-transplantation strategy. 10,11 Here, we report for the first time the treatment of severe AR in a patient with a PF-BiVAD by performing TAVR using two Edwards SAPIEN 3 (Edwards Lifesciences, Irvine, California, USA) bioprostheses as a valve-in-valve procedure. 9 Moreover, most patients with VAD and progressive AR present several co-morbidities and are demanding to (re-)operate, posing them to high or prohibitive surgical risk.…”

“…Considering this, percutaneous methods of intervention including TAVR and occlude devices have emerged as alternative treatment strategies in patients with VADs. 10,11 However, there is a very scarce experience of TAVR in this setting of patients, mainly focused on CF-VAD technology. 10,11 Here, we report for the first time the treatment of severe AR in a patient with a PF-BiVAD by performing TAVR using two Edwards SAPIEN 3 (Edwards Lifesciences, Irvine, California, USA) bioprostheses as a valve-in-valve procedure.…”

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

“…Lack of annular calcium makes TAVR anchoring less certain, increasing risk of prosthesis migration after release. For example, Phan et al reviewed 29 reports of LVAD patients receiving transcatheter intervention for aortic insufficiency, including 8 patients who received TAVR . Even in this small cohort, two patients (25%) had device migration after implantation.…”