First-in-Man Transfemoral Transcatheter Aortic Valve Implantation for Severe Aortic Regurgitation in a Patient with Left Ventricular Assist Device

Abstract

Purpose Patients with left ventricular assist device (LVAD) may develop significant aortic regurgitation (AR) and require high-risk surgical intervention. Transcatheter aortic valve implantation (TAVI) has emerged as a therapeutic alternative for patients with severe aortic stenosis not amenable for surgery but has also been used in high risk patients for pure AR with good results. We report the first-in-man case of transfemoral (TF) TAVI in an LVAD patient with severe AR. Methods and Materials A 55 year old female with severe idiopathic dilated cardiomyopathy underwent HeartMate II LVAD implantation on November 2010 as bridge to transplant. Following a hemodynamic uneventful one year at home she gradually developed symptoms of severe left heart failure and echo showed severe non calcified AR. Our local Heart Team recommended TF TAVI as the preferred option and after discussing the options the patient gave her consent for that approach. The procedure was performed on August 8, 2012, under mild sedation without reduction or interruption of the LVAD rotation speed (9400 rpm). The right femoral artery was used for access under local anesthesia and an 18Fr guiding sheath was introduced percutaneously. No pre-dilation of the aortic valve was performed. A stiff guide-wire was placed in the left ventricle, carefully avoiding its entrapment in the LVAD apical inflow cannula, and a 29mm CoreValve (Medtronic, Minneapolis, MN) was implanted without need for rapid pacing. Aortography showed minimal residual AR and no blockage of the LVAD outflow graft in the ascending aorta. The patient was stable hemodynamicaly throughout the procedure and recovered with no complications. Echo on the second post-TAVI day showed no residual AR and she was discharged home. On 3 months follow up her clinical status has improved significantly and she remains with no AR on repeat echo studies. Results TF TAVI should be considered as a safe and viable solution for severe AR in LVAD patients.