Concurrent Mitral Valve Repair during Placement of Continuous-Flow Left Ventricular Assist Device

Abstract

Purpose Pre-existing mitral valve pathology is common in patients undergoing continuous-flow left ventricular assist device (LVAD) implantation. Best management of pre-existingmitral valve disease remains controversial. Methods Between March 2004 and December 2017, a total of 594 patients received a continuous-flow left ventricular assist device. Of these, a total of 93 patients (16%) underwent a concurrent mitral valve repair, either with an Alfieri stitch via the left ventricular (LV) apex coring site (n =30, 32%) or with an annuloplasty ring via a left atriotomy (n = 63, 68%). Outcomes were compared between patients who received an Alfieri stitch and those who received an annuloplasty ring repair. Results All patients had moderate or greater mitral regurgitation at the time of LVAD implantation. Median age was 54 years (interquartile range [IQR], 43-74) in the annuloplasty cohort, and 56 years (interquartile range [IQR], 44-79) in the Alfieri stitch group. A proportionately greater number of women underwent Alfieri stitch repair (n = 6, 20%) compared to ring annuloplasty (n = 5, 8%; p = 0.01). Additionally, a greater number of patients in the Alfieri group underwent a concomitant valve intervention such as a Park stitch or tricuspid repair (n = 15, or 50%) compared to those patients undergoing a ring annuloplasty (n = 28, 44%; p = 0.04). Cardiopulmonary bypass times were shorter on average in the Alfieri patients, independent of concomitant valve procedure (111 minutes versus 134 minutes, p = .02). Thirty-day survival in the Alfieri group (n = 27, 90%) was similar to that of the ring annuloplasty group (n = 57, 91%); p > 0.05. However, in the 84 patients for whom data was available, 1-year survival was higher in the Alfieri group compared to the ring annuloplasty group (26.3% versus 18.6%, p = 0.032). Conclusion Concomitant mitral valve intervention is fairly common in patients undergoing continuous-flow LVAD placement. Our findings suggest that short-term outcomes are not impacted by type of mitral valve repair technique, but mitral valve repair via the LV apex coring site may be a favorable approach.