Progression of aortic insufficiency with durable mechanical support.

Abstract

As survival rates with continuous flow left ventricular assist device (LVAD) support have improved, the use of these devices as permanent therapy has considerably expanded [1]. Destination therapy refers to this long-term use of LVADs as an alternative to transplantation in patients with end-stage heart failure who are ineligible for transplantation. The current, third generation of LVADs, such as the HeartMate 3 (HM3, Abbott Inc, Chicago, IL, USA), is more durable than their predecessors and has lower complication rates [2]. Patients can be maintained on them for much longer with lower morbidity, making destination therapy now a realistic option. Development of de novo aortic insufficiency (AI) has been observed in up to a third of patients supported by a continuous flow LVAD [3–5]. Worse clinical outcomes have been reported among patients suffering from significant AI while on support [6]. Development of symptomatic AI negatively impacts haemodynamics, increases rehospitalizations for heart failure and decreases survival on continuous flow LVAD support [6]. Thorough assessment of aortic valve functionality is mandated in the decision process for durable LVAD implantation. Those LVAD candidates that suffer from greater than mild AI should be treated with concomitant aortic valve surgery. Contemporary approach in these patients is aortic valve replacement with a biological prosthesis. Mechanical prostheses are contraindicated, due to persistent AI associated with mechanical valve design as well as increased risk of thrombus formation. Park’s central stitch, a simple central coaptation stitch, has been used to reduce AI in patients on continuous flow LVAD support who develop significant insufficiency and some surgeons have proposed prophylactic use of this stitch at the time of device implantation to prevent this complication [7]. Transcatheter aortic valve implantation (TAVI) might be considered as an off-label strategy.