Uncorrected pre-operative mitral valve regurgitation is not associated with adverse outcomes after continuous-flow left ventricular assist device implantation

Stulak, John M.; Tchantchaleishvili, Vakhtang; Haglund, Nicholas; Davis, Mary E.; Schirger, John A.; Cowger, Jennifer; Shah, Palak; Aaronson, Keith D.; Pagani, Francis D.; Maltais, Simon

doi:10.1016/j.healun.2014.11.023

Cited by 58 publications

(55 citation statements)

References 11 publications

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“…Our mortality and morbidity was low, and in keeping with that of contemporary series of LVAD implantation. 9,15 We believe that certain aspects of our approach are key to safely performing mitral surgery at time of LVAD implantation. Avoiding aortic clamping may help preserve right ventricular function by reducing intraoperative ischemic injury.…”

Section: Discussionmentioning

confidence: 99%

Mitral valve repair for severe mitral valve regurgitation during left ventricular assist device implantation

Pawale

Itagaki

Parikh

et al. 2019

The Journal of Thoracic and Cardiovascular Surgery

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Background: The management of severe mitral regurgitation (MR) at the time of left ventricular assist device (LVAD) implantation is controversial. We adopted an approach of systematic repair of severe MR at the time of LVAD implantation and report our experience.Methods: We performed mitral valve repair (MVr) on 78 consecutive patients with severe MR undergoing LVAD implantation at our institution between 2013 and 2017. We compared data on these patients to 28 historical controls with severe MR from the immediate preceding period between 2011 and 2013 where the MR was not treated, using Cox modeling and propensity score methods. Median follow-up time was 17.7 months.From the

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Section: Discussionmentioning

confidence: 99%

Mitral valve repair for severe mitral valve regurgitation during left ventricular assist device implantation

Pawale

Itagaki

Parikh

et al. 2019

The Journal of Thoracic and Cardiovascular Surgery

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“…Significant preoperative mitral regurgitation (MR) is thought to decrease after LVAD implantation and for this reason correction of MR is not indicated if ventricular recovery is not expected . Speed optimization—with the target mean arterial pressure 65–85 mm Hg, parallel positioning along the interventricular septum, intermittent opening of aortic valve, and less than moderate MR—should be done for appropriate ventricular unloading before discharge .…”

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confidence: 99%

Impact of Residual Mitral Regurgitation on Right Ventricular Systolic Function After Left Ventricular Assist Device Implantation

et al. 2016

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Significant mitral regurgitation (MR) is thought to decrease after left ventricular assist device (LVAD) implantation, and therefore repair of mitral valve is not indicated in current practice. However, residual moderate and severe MR leads to pulmonary artery pressure increase, thereby resulting in right ventricular (RV) dysfunction during follow-up. We examined the impact of residual MR on systolic function of the right ventricle by echocardiography after LVAD implantation. This study included 90 patients (mean age: 51.7 ± 10.9 years, 14.4% female) who underwent LVAD implantation (HeartMate II = 21, HeartWare = 69) in a single center between December 2010 and June 2014. Echocardiograms obtained at 3-6 months and over after implantation were analyzed retrospectively. RV systolic function was graded as normal, mild, moderate, and severely depressed. MR (≥moderate) was observed in 43 and 44% of patients at early and late period, respectively. Systolic function of the RV was severely depressed in 16 and 9% of all patients. Initial analysis (mean duration of support 174.3 ± 42.5 days) showed a statistically significant correlation between less MR and improved systolic function of RV (P = 0.01). Secondary echocardiographic analysis (following a mean duration of support of 435.1 ± 203 days) was also statistically significant for MR degree and RV systolic dysfunction (P = 0.008). Residual MR after LVAD implantation may cause deterioration of RV systolic function and cause right-sided heart failure symptoms. Repair of severe MR, in selected patients such as those with severe pulmonary hypertension and depressed RV, may be considered to improve the patient's clinical course during pump support.

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“…Implantation of a LVAD leads to unloading of the LV, followed by a reduction in the LVEDV and mitral valve annular diameter, which would consequently result in a decrease in MR severity. Hence, a simultaneous mitral valve procedure is not recommended at the time of CF‐LVAD implantation . To our knowledge, only a few clinical studies regarding MR in patients receiving CF‐LVAD support have been conducted thus far.…”

Section: Discussionmentioning

confidence: 99%

“…Regurgitant flow is usually reduced under LVAD support, and volume unloading of the left ventricle (LV) leads to a reduction in mitral annular dilatation, followed by an improvement of MR. Although there is a general consensus that patients receiving CF‐LVAD do not require MR treatment at the time of LVAD implantation , the need for surgical repair in patients with severe MR or in patients receiving partial support is controversial. Excessive volume unloading of the LV can affect right ventricular (RV) function by causing a leftward shift of the interventricular septum (IVS; 3).…”

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confidence: 99%

What Is the Optimal Setting for a Continuous‐Flow Left Ventricular Assist Device in Severe Mitral Regurgitation?

et al. 2016

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Excessive left ventricular (LV) volume unloading can affect right ventricular (RV) function by causing a leftward shift of the interventricular septum in patients with mitral regurgitation (MR) receiving left ventricular assist device (LVAD) support. Optimal settings for the LVAD should be chosen to appropriately control the MR without causing RV dysfunction. In this study, we assessed the utility of our electrocardiogram-synchronized rotational speed (RS) modulation system along with a continuous-flow LVAD in a goat model of MR. We implanted EVAHEART devices after left thoracotomy in six adult goats weighing 66.4 ± 10.7 kg. Severe MR was induced through inflation of a temporary inferior vena cava filter placed within the mitral valve. We evaluated total flow (TF; the sum of aortic flow and pump flow [PF]), RV fractional area change (RVFAC) calculated by echocardiography, left atrial pressure (LAP), LV end-diastolic pressure (LVEDP), LV end-diastolic volume (LVEDV), and LV stroke work (LVSW) with a bypass rate (PF divided by TF) of 100% under four conditions: circuit-clamp, continuous mode, co-pulse mode (increased RS during systole), and counter-pulse mode (increased RS during diastole). TF tended to be higher in the counter-pulse mode. Moreover, RVFAC was significantly higher in the counter-pulse mode than in the co-pulse mode, whereas LAP was significantly lower in all driving modes than in the circuit-clamp condition. Furthermore, LVEDP, LVEDV, and LVSW were significantly lower in the counter-pulse mode than in the circuit-clamp condition. The counter-pulse mode of our RS modulation system used with a continuous-flow LVAD may offer favorable control of MR while minimizing RV dysfunction.

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Uncorrected pre-operative mitral valve regurgitation is not associated with adverse outcomes after continuous-flow left ventricular assist device implantation

Cited by 58 publications

References 11 publications

Mitral valve repair for severe mitral valve regurgitation during left ventricular assist device implantation

Mitral valve repair for severe mitral valve regurgitation during left ventricular assist device implantation

Impact of Residual Mitral Regurgitation on Right Ventricular Systolic Function After Left Ventricular Assist Device Implantation

What Is the Optimal Setting for a Continuous‐Flow Left Ventricular Assist Device in Severe Mitral Regurgitation?

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