Invited Commentary

Abstract

As our collective experience with mechanical circulatory support as a treatment for advanced heart failure grows, we have an improved understanding of the physiologic impact of continuous-flow left ventricular assist device (LVAD) therapy. Dr Goodwin and colleagues [1Goodwin M. Nemeh H.W. Borgi J. Paone G. Morgan J.A. Resolution of mitral regurgitation with left ventricular assist device support.Ann Thorac Surg. 2017; 104: 811-819Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar] report on their evaluation of the impact of preoperative mitral regurgitation on postoperative outcomes after LVAD implantation. Unsurprisingly, they find that preoperative mitral regurgitation, regardless of severity, does not affect postoperative patient outcomes. Furthermore, LVAD implantation results in reverse remodeling of the left ventricle and durable improvement in mitral regurgitation. These findings confirm those of Dr Stulak and colleagues [2Stulak J.M. Tchantchaleishvili V. Haglund N.A. et al.Uncorrected pre-operative mitral valve regurgitation is not associated with adverse outcomes after continuous-flow left ventricular assist device implantation.J Heart Lung Transplant. 2015; 34: 718-723Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar], who previously reported that uncorrected mitral regurgitation had no impact on post-LVAD outcomes. Whereas the majority of patients undergoing LVAD implantation have secondary mitral regurgitation, the cause of mitral valve dysfunction becomes irrelevant once ventricular function has deteriorated to the point of requiring mechanical circulatory support. LVAD therapy directly unloads the left ventricle and actively reduces left-ventricular end diastolic pressure (LVEDP) [3Soucy K.G. Bartoli C.R. Phillips D. et al.Continuous-flow left ventricular assist device support improves myocardial supply:demand in chronic heart failure.Ann Biomed Eng. 2017; 45: 1475-1486Crossref PubMed Scopus (9) Google Scholar]. The improvement in heart failure symptoms, respiratory symptoms in particular, is in large part due to this reduction in LVEDP and improvement in mitral regurgitation. This physiologic finding should not be construed as an indication for mitral valve procedures in the context of durable LVAD implantation. The care of patients with advanced heart failure requiring LVAD therapy is complex and fraught with risks. Advocating additional procedures for marginal gain in hemodynamic parameters may not yield significant improvements in patient outcomes. We may be best served to remember Antoine de Saint-Exupery’s maxim: “Perfection is achieved, not when there is nothing more to add, but when there is nothing more to take away.” Resolution of Mitral Regurgitation With Left Ventricular Assist Device SupportThe Annals of Thoracic SurgeryVol. 104Issue 3PreviewCardiac valve disease is common in patients with end-stage heart failure undergoing left ventricular assist device implantation (LVAD). The aim of this study was to determine if preoperative mitral regurgitation (MR) affects outcomes and hemodynamics in patients after LVAD implantation. Full-Text PDF