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

Abstract

Aortic insufficiency following left ventricular assist device implantation (LVAD) has been reported in up to 40% of patients and is associated with a worse prognosis. We describe the case of a successful transfemoral transcatheter aortic valve replacement with a self-expanding bioprosthesis for aortic insufficiency following destination LVAD implantation.

Mitral bioprosthetic valve leaflet fusion treated by balloon valvuloplasty in patients on ECMO

“…A similar situation involving the aortic valve has been reported in patients with a left ventricular assist device. This effect is described in both bioprosthetic and native valves …”

Transcatheter aortic valve replacement: A potential option for aortic insufficiency management in patients with left ventricular assist device

“…However, CF-LVAD has its unique sets of challenges and complications that were not observed with pulsatile LVADs [5]. Incidence of denovo aortic insufficiency (AI) in CF-LVAD patients can be as high as 30–40% and worsens with time [6], [7], [8]. LVAD efficacy diminishes in the presence of moderate to severe AI [7].…”

“…Moderate to severe AI warrants urgent attention as per International Society of Heart and Lung Transplant (ISHLT) guidelines as a significant portion of blood flow from outflow cannula in the proximal ascending aorta can return back to left ventricle (LV) [7], [10]. Increase in pump output can temporize the situation but at the cost of potentially increasing AI [6]. Unintervened AI not only reduces systemic perfusion, but also leads to LV distension, increased work load on the pump and eventually increased right heart afterload and right ventricular failure.…”

“…Both Rene et al and D’Ancona et al slightly oversized AV for LAVD patients since position of the inflow cannula into LV apex can impact valve position or even lead to valve migration into LV. Additionally, oversizing the valve gives more room for better anchoring the valve in the AV annulus [6], [13]. Rene and coauthors have also postulated that at least 15% oversizing is necessary to avoid valve migration [6].…”

Commentary: When less is more: Is valve repair the optimal intervention for aortic insufficiency at time of ventricular assist device implantation?

“…Although transcatheter approaches have been reported to treat the development of de novo AI, this area remains largely anecdotal and remains to be fully investigated for this off-label use. 3 More than 30% of patients develop de novo, greater-thanmoderate AI by 2 years after LVAD implantation. 4 Existing AI, as in the case presented by Barac and colleagues 5 in this issue of the Journal, must be addressed at the time of implantation.…”