Transcatheter aortic valve repair for management of aortic insufficiency in patients supported with left ventricular assist devices

Abstract

The development of new aortic insufficiency after a period of support with a left ventricular assist device can result in progressive heart failure symptoms. Transcatheter aortic valve repair can be an effective treatment in selected patients, but the lack of aortic valve calcification can result in unstable prostheses or paravalvular leak. We describe a technique of deploying a self-expanding CoreValve (Medtronic, Minneapolis, MN, USA) into the aortic annulus, followed by a balloon-expandable SAPIEN-3 (Edwards, Irvine, CA, USA).

Transfemoral transcatheter aortic valve replacement with a self-expanding valve for severe aortic regurgitation in a patient with left ventricular assist device

“…Of the six cases performed with a Medtronic Corevalve, one required further post‐dilation for residual aortic regurgitation and two experienced ventricular migration of the transcatheter valve, one of which was treated with the implantation of a second Corevalve . Two required additional implantation of a balloon‐expandable Edwards Sapien S3 prosthesis to treat significant residual paravalvular leak . Although we did not have stable fixation of the valve at first, following removal of the first valve and implantation of a new transcatheter valve starting at a more aortic position with the top of the valve cage resting on the LVAD outflow cannula, we were able to obtain both valve stability and total resolution of the aortic insufficiency.…”

“…Appropriate oversizing is of utmost importance to maximize anchoring of the valve at the annulus, to reduce the possibility of ventricular migration, and to optimize hemodynamics in the setting of a LVAD. Of the previous seven cases of TAVR in patients with LVAD and aortic valve insufficiency in non‐calcified or minimally calcified aortic valve described in the literature, only one was performed with a balloon‐expandable valve as the sole valve . Of the six cases performed with a Medtronic Corevalve, one required further post‐dilation for residual aortic regurgitation and two experienced ventricular migration of the transcatheter valve, one of which was treated with the implantation of a second Corevalve .…”

Transcatheter valvular therapies in patients with left ventricular assist devices

“…In the first reported case of TAVR in a patient with LVAD, D'Ancona et al used a 29 mm SAPIEN valve within a 21 mm annulus that would normally require a 23 mm valve ( 13 ). Pal et al successfully deployed a 31 mm CoreValve -oversized by 17%- followed by a 29 mm valve-in-valve SAPIEN-3 in two patients with CF-LVAD ( 47 ). The CoreValve fixation within the aorta served as a scaffold to anchor the SAPIEN-3 in the absence of annular calcifications, while the SAPIEN-3 eliminated paravalvular leakage once overinflated.…”

Pathophysiology and management of valvular disease in patients with destination left ventricular assist devices

“…Conventional surgical approaches to ameliorate post-LVAD AI have been carried out with good results, accepting the risks of redo sternotomy and right ventricular injury as well as failure ( 32 ). In order to reduce procedural risk in this cohort of comorbid patients, percutaneous transcatheter approaches including transcatheter aortic valve replacement (TAVR) and percutaneous occlude devices of native or bioprosthetic prostheses have been developed ( 33 – 36 ). In a systematic review and meta-analysis of percutaneous transcatheter interventions for AI in continuous flow LVAD, TAVR and occlude devices demonstrated similar efficacy in significantly reducing severe AI ( 37 ).…”