Development of Aortic Regurgitation After LVAD Implantation with Descending Thoracic Aorta Anastomosis Technique

Abstract

<h3>Introduction</h3> Aortic regurgitation (AR) is a complication of LVAD support. Prevalence raises 30%. Left thoracotomy (LT) access and descending thoracic aorta anastomosis technique (DTAAT) avoid conventional sternotomy complications, especially with patients with previous coronary artery bypass grafts (CABG), those with previous sternotomies or porcelain aorta. We describe two cases of severe AR after LVAD implantation with DTAAT. <h3>Case Report</h3> First case is a 70 y-o-male with advanced heart failure (HF) due to dilated ischaemic cardiomyopathy (ICM) with previous CABG. LVEF was 25%. In June 2019, he had a HM3 (HeartMate III, St. Jude Medical) implantation by LT. The initial plan was to anastomose the outflow graft to the ascending aorta but due to calcified plaques, DTAA was done. Postoperative course included hemothorax. On discharge, there was pulsatility and patient reached high dose of vasodilators. His LVAD parameters: 5100 rpm, 3.1 Lpm, PI 6-7. After 803 days on support, in August 2021, he was admitted due to an ulcerative colitis flare-up. Natriuretic peptides were high and a transoesophageal echocardiogram (TOE) revealed a significant aortic regurgitation which is pending of a TAVR procedure. Second case is a 73 y-o-male with advanced HF due to dilated ICM with previous CABG. LVEF was 15%. In December 2019, he had a HM3 implantation by LT. Due to CABG (internal mammary artery to the descending coronary artery) near the sternum, a DTAAT was performed. Postoperative course included left hemothorax and politrasfusion. Early after, the aortic valve was closed with 5200 rpm, 4.1Lpm, PI 4-5 and echocontrast was noticed in the aortic root. Later on a thrombus was evidenced above the non coronary cusp. After 354 days on support, in December 2020, he went into pulmonary oedema. A TOE revealed a torrential AR with was successfully treated with an urgent TAVR. <h3>Summary</h3> We report two cases of AR after DTAAT in which the aetiology could be related to a minor wash out of the aortic root. DTAAT is particularly applicable for patients with a history of previous cardiac surgery and usually done in destination therapy cases because the anastomosis to the descending aorta can be hard to reach during transplantation. DTAAT should be applicable to patients with increased ventricle dimensions and if aortic valve is closed, a surveillance of thrombus formation and AR development should be advised.