Percutaneous closure of an incompetent aortic valve using an occluder device in a patient with left ventricular assist device

Transcatheter valvular therapies in patients with left ventricular assist devices

Aortic, mitral and tricuspid valve regurgitation are commonly encountered in patients with continuous-flow left ventricular assist devices (CF-LVADs). These valvular heart conditions either develop prior to CF-LVAD implantation or are induced by the pump itself. They can all have significant detrimental effects on patients' survival and quality of life. With the improved durability of CF-LVADs and the overall rise in their volume of implants, an increasing number of patients will likely require a valvular heart intervention at some point during CF-LVAD therapy. However, these patients are often considered poor reoperative candidates. In this context, percutaneous approaches have emerged as an attractive "off-label" option for this patient population. Recent data show promising results, with high device success rates and rapid symptomatic improvements. However, the occurrence of distinct complications such as device migration, valve thrombosis or hemolysis remain of concern. In this review, we will present the pathophysiology of valvular heart disease in the setting of CF-LVAD support to help us understand the underlying rationale of these potential complications. We will then outline the current recommendations for the management of valvular heart disease in patients with CF-LVAD and discuss their limitations. Lastly, we will summarize the evidence related to transcatheter heart valve interventions in this patient population.

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

OBJECTIVE

Aortic insufficiency (AI) develops in 25% of patients after left ventricular assist device (LVAD) insertion. The objective of this study was to evaluate the occurrence of new-onset AI upon initiation of cardiopulmonary bypass (CPB) required for LVAD insertion and the potential ability of this new-onset AI to predict development of post-LVAD insertion AI.

DESIGN

Forty-one patients undergoing LVAD insertion were studied. Intraoperative transesophageal echocardiography (TEE) evaluation was performed at baseline (post-induction, pre-sternotomy), 5 minutes after CPB initiation, and post-chest closure. Patients were followed up postoperatively for development of AI.

SETTING

Single university hospital.

PARTICIPANTS

Patients undergoing elective LVAD insertion.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

At baseline, 35 patients exhibited none-trace AI, 4 exhibited mild AI, 2 exhibited moderate AI, and none exhibited severe AI. After initiation of CPB, 34 patients exhibited no change in degree of AI yet 7 exhibited an increase in AI severity. However, all 7 patients exhibited no change in degree of AI at chest closure and one exhibited a decrease in AI severity. Four patients developed at least moderate AI during the postoperative period (range 3-8 months). However, only one of these patients exhibited an increase in AI severity after initiation of CPB for LVAD insertion. No significant changes in aortic root measurements were observed during the entire intraoperative period (within patients nor between patients with/without development of at least moderate postoperative AI).

CONCLUSIONS

One in 5 patients undergoing LVAD insertion will demonstrate an increase in AI severity at CPB initiation without changes in aortic root measurements. None of the information obtained from intraoperative TEE seemed to predict development of at least moderate postoperative AI.