Concomitant mitral valve procedures in patients undergoing implantation of continuous-flow left ventricular assist devices: An INTERMACS database analysis

Practical valvular issues in patients requiring ventricular assist devices

PURPOSE OF REVIEW

As ventricular assist device (VAD) therapy in patients with advanced heart failure continues to grow, experience with concomitant valvular diseases present either before or after VAD implantation continues to accrue. In this review, we discuss recent data and current practice as it pertains to the subject of concomitant valvular disease in patients requiring VADs.

RECENT FINDINGS

Persistent aortic valve closure has been identified as a potential contributor to aortic valve 'disuse atrophy' resulting in valve degeneration. Dilation of the aortic root may be predictive of future development of aortic insufficiency. Novel echocardiographic parameters to identify the severity of aortic insufficiency following VAD implantation may be useful for risk stratification. Concomitant repair of significant mitral regurgitation may confer benefit to pulmonary vascular resistance and right ventricular function; however, this remains controversial. Concomitant repair of significant tricuspid regurgitation has not demonstrated early postoperative benefit nor survival benefit. Atrial fibrillation has emerged as a risk factor that may predict accelerated progression of postoperative tricuspid regurgitation.

SUMMARY

Management of aortic insufficiency, mitral regurgitation or tricuspid regurgitation in patients requiring VADs continues to be the source of controversy. As experience accrues with varying strategies to prevent or manage these valvular lesions, our understanding of the impact of these strategies continues to evolve.

Safety of centrifugal left ventricular assist device in patients previously treated with MitraClip system

INTRODUCTION

No data regarding the safety of continuous-flow left ventricular assist device (CF-LVAD) implantation in patients with previous MitraClip have been reported. Thus, it remains unknown whether an initial treatment strategy with MitraClip therapy might complicate future heart failure management in patients who are also considered for CF-LVAD.

METHODS

We retrospectively identified 6 patients (median age of 62 years; 2 women) who had been treated with MitraClip, that were eventually implanted with a CF-LVAD (all Heartware HVAD) in 3 hospitals between 2013 and 2018.

RESULTS

Patients were treated in 4 cases with 2 clips, and in 2 cases with 1 clip. Median time from MitraClip implantation to CF-LVAD implant was 282 days (interquartile range 67 to 493), and median time on CF-LVAD support was 401 days (interquartile range 105 to 492 days). Two patients underwent a heart transplant, 3 patients died on support, and 1 is alive on support. In all cases, there was a reduction of functional mitral regurgitation without MitraClip-related complications.

CONCLUSIONS

Based on this small case series, implantation of a CF-LVAD appears safe in patients with a previously positioned MitraClip system, at least, with 1 or 2 clips in place, with no need for additional mitral valve surgery.

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

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.

RESULTS

Patients who underwent MVr were younger than those who did not (non-MVr group) (55 vs 63 years; P = .006), but otherwise had similar preoperative characteristics. The incidence of 30-day mortality (2.6% vs 3.6%; P = .78) and other early major adverse events was similar in both groups. At 3 months, no patient in the MVr group had more than mild MR compared with 7 patients (29%) in the non-MVr group (P < .001). Cardiac catheterization done 3 to 6 months after surgery showed tendency toward greater reduction from preoperative pulmonary artery systolic pressure in the MVr group compared with the non-MVr group (-20 vs -13 mm Hg; P = .10). The cumulative incidence of readmission due to congestive heart failure at 2 years was lower in the MVr group than in non-MVr group (7.1% vs 19.7%; adjusted hazard ratio, 0.18; 95% confidence interval, 0.04-0.76; P = .02).

CONCLUSIONS

Concurrent MVr at the time of LVAD implantation can be done safely without increase in perioperative adverse events. MVr may be associated with better reduction in severity of MR and may have potential benefit in terms of reduction in readmissions for heart failure.

Surgical Implantation of Intracorporeal Devices: Perspective and Techniques

Surgical maneuvers for implantation of a continuous-flow ventricular assist device are revolutionary concepts that have been associated with a reduction in pump-related complications. With the advancement of technology, surgical implant strategy continues to evolve, incorporating less-invasive approaches into the armamentarium of the experienced surgeon.

Mitral Intervention with LVAD: Preparing for Recovery

Left ventricular assist device (LVAD) insertion is an increasingly common treatment of advanced heart failure. Insertion guidelines suggest regurgitant lesions of the mitral valve should not be addressed. However, recent evidence suggests that mitral regurgitation may not necessarily improve with LVAD insertion, and such patients may have worse outcomes. Thus, practice variability is high given the discrepancy between traditional thinking and new evidence that unrepaired mitral regurgitation may increase perioperative mortality. Additionally, the challenges of LVADs can make transesophageal echocardiography evaluation and assessment of mitral valve pathology difficult.