Fusion of Bovine Tissue Aortic Valve Leaflets in a Patient with Left Ventricular Assist Device: A Case Report

Abstract

<h3>Introduction</h3> We present a case of a patient with prior bioprosthetic aortic valve replacement who underwent Left Ventricular Assist Device (LVAD) explant and was found to have fused valve leaflets at the time of surgery. <h3>Case Report</h3> The patient is a 30 year old woman with a history of a congenital quadricuspid aortic valve (frequency < 0.05%), complicated by myocardial infarction and cardiogenic shock with LVEF 5% due to occlusion of the left main coronary ostium by rupture of one of the leaflets. She required support via Veno-Arterial ExtraCorporeal Membrane Oxygenation (VA-ECMO) followed by Aortic Valve Replacement with #23 Bovine Tissue Valve and HeartMate 3™ (Abbot Laboratories) implantation in January 2019. Her LVEF improved to 55% after 6 months of mechanical circulatory support. The patient was scheduled for LVAD explant 9 months after implant. Intraoperative transesophageal echocardiogram showed leaflet fibrosis & severe functional closure of her prosthetic aortic valve and left ventricular outflow tract, not seen on prior echocardiograms (Figure 1). We performed an LVAD explant via redo sternotomy and left anterolateral thoracotomy, redo-aortic valve replacement with a #19 mechanical valve, and ventriculotomy closure using custom made synthetic plug. She is doing well 13 months after surgery. <h3>Summary</h3> Patients with prior tissue aortic valve replacement require careful preoperative evaluation before LVAD explant. Though we had a good outcome, pre-procedural knowledge of valve dysfunction is critical in surgical planning. We have developed an algorithm which may be utilized in the future to improve outcomes (Figure 2).