TAVI in LVAD Patients with Aortic Insufficiency

Abstract

Purpose Development of aortic insufficiency (AI) following durable left ventricular assist device (LVAD) implantation is common, and is associated with a worse prognosis. Transcatheter aortic valve implantation (TAVI) has become a mainstay therapy for high- and intermediate-risk patients with severe aortic stenosis , with an off-label use for severe AI. The aim of this study was to assess the feasibility and durability of TAVI in LVAD patients with severe AI. Methods We evaluated all LVAD patients within our database that underwent TAVI for aortic insufficiency between 4/2014-9/2018. Clinical and echocardiographic data were collected before and after TAVI procedure. Aortic regurgitant fraction (RF) was calculated using outflow graft velocities. Results 6 patients underwent 8 attempted TAVI procedures. Mean age was 68 ±7 years, 33% were female, 33% received LVAD as bridge-to-transplant, and 66% as destination therapy. Average time from LVAD to TAVI was 32 ±25 months. Implanted valves included Edwards Sapien 3 (4), Medtronic CoreValve (3), and Medtronic Evolut R (1). Following TAVI procedure, 5 patients (83%) survived over a mean follow-up of 11 ±16 months, and 1 patient died of peri-procedural complications following device deployment. 1 procedure was aborted due to vascular complications, and this patient subsequently underwent TAVI 28 days later. 1 patient underwent 2 separate TAVI procedures 1.8 years apart. Median length of hospitalization was 7.5 days (IQR 6.3-15.5). Procedural success was achieved in 75% of attempts, with significant improvement in RF from 44.8% (IQR 37.6-63.6) pre-procedurally to 27.3% (IQR 8.5-30.0, p=0.041) immediately post-TAVI. This remained unchanged on 1-month echocardiographic follow-up with RF of 26.1% (IQR 10.6-29.9, p=0.72). Qualitative trace or mild peri-valvular leak was noted on all surviving patients at 1-month follow-up. Conclusion TAVI is a clinically reasonable therapy for treating LVAD induced AI. Longer follow-up is needed to assess the durability and long-term efficacy of this procedure.