Can Intraoperative Transesophageal Echocardiography Predict Postoperative Aortic Insufficiency in Patients Receiving Implantable Left Ventricular Assist Devices?

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.

Role of Echocardiography in the Evaluation of Left Ventricular Assist Devices: the Importance of Emerging Technologies

The role of left ventricular assist devices (LVAD) in patients with end-stage heart failure is well known, both as a temporary treatment before transplantation and as destination therapy, in a scenario of a relative shortage of donors to satisfy the increasing requests for transplantation. The increased population of LVAD patients needs careful imaging assessment before, during, and after LVAD implantation; echocardiography is the best tool for their evaluation and is considered the diagnostic technique of choice for the assessment before, during, and after device implantation. Although the conventional echocardiographic assessment is quite effective in evaluating the main critical issues, the role of new technologies like three-dimensional echocardiography and myocardial deformation measurements is still not properly clarified. In this review, we aim to provide an overview of the main elements that should be considered in the assessment of these patients, underlining the role that could be played by new techniques to improve the diagnostic and prognostic effectiveness of echocardiography in this setting.

[Intensive care treatment of patients with left ventricular assist devices]

Apart from heart transplantation, implantation of a left ventricular assist device (LVAD) is the only established surgical treatment for therapy-refractory terminal left heart failure, The specific intensive care unit (ICU) management of these patients depends on the reason for the ICU admission and requires understanding of the characteristic hemodynamics of non-pulsatile LVADs as well as of the inherent problems. Knowledge about the specific features in hemodynamic monitoring, understanding of pump characteristics, management of anticoagulation and hemostasis and the handling of problems, such as right heart failure, aortic valve insufficiency and infections is essential. The management of unconscious LVAD patients can be challenging. It requires a sophisticated transthoracic and transesophageal echocardiography (TTE/TEE) examination, targeted laboratory diagnostics and consideration of possible alternative diagnoses. Professional interdisciplinary cooperation and exchange of current knowledge is crucial.