Patch closure of the aortic anulus in a recipient of a ventricular assist device

Abstract

Management of the prosthetic aortic valve continues to be a challenge in those patients who require left ventricular mechanical assistance. If left in situ, the indwelling mechanical prosthesis may increase the risk of cerebral thromboembolism. A frequent solution has been valve re-replacement with a bioprosthesis, which may reduce the thromboembolic risk but may not obviate the need for anticoagulation. We describe in this report our experience with such a patient and a novel approach to avoid valve re-replacement with patch closure of the aortic anulus. Clinical summary. A 55-year-old man who had received a Starr-Edwards aortic valve (Baxter Healthcare Corp, Edwards Division, Santa Ana, Calif) some 25 years earlier had a massive anterolateral myocardial infarction. This resulted in severe mitral regurgitation, pulmonary edema, and cardiogenic shock. An angioplasty of the occluded left anterior descending coronary artery was performed successfully but did not restore ventricular function. He was transferred to our center intubated with an intra-aortic balloon pump in place and supported with multiple inotropic agents. After clinical stabilization and rapid work-up for transplantation had been completed, it became apparent that mechanical ventricular assistance was his only chance for survival until a donor heart became available. The patient underwent successful placement of a TCI HeartMate 1000 IP left ventricular assist device (LVAD; Thermo Cardiosystems Inc, Woburn, Mass). At the time of surgery, we thought that the existing prosthetic aortic valve should be removed to prevent the risk of perivalvular thromboembolism and the need for anticoagulation. A vertical aortotomy was performed anteriorly, which was later used for the outflow graft anastomosis. Attempts at permanent closure of the ball valve were unsuccessful because the ball could not be pierced with a needle. Through this exposure the struts of the valve were transected at their junction with the sewing ring and removed together with the ball valve, leaving the original and well-incorporated sewing ring in place. The aortic anulus