TAVR Thrombosis in Patient Supported with Durable Left Ventricular Assist Device

Abstract

Introduction Aortic incompetence (AI) is very common complication after continuous flow left ventricular assist device (LVAD) implantation, and can result in increased symptoms for LVAD patients. Recent advances in Transcatheter Aortic Valve Replacement (TAVR) technology has resulted in this becoming a potential therapeutic avenue for LVAD patients with AI. We report a case of TAVR implantation in a patient supported with a LVAD complicated by thrombosis. Case Report A 61-year-old female presented with STEMI. She was treated with primary PCI, but had progressive cardiogenic shock and was placed on VA-ECMO. Due to high PRA, she was unable to be listed for primary transplantation and underwent implantation of a Heartware LVAD (Medtronic) as bridge to decision. Her post-operative course was complicated by recurrent GI bleeding. Over the following 12 months, she was noted to have worsening AI on routine echocardiography, with worsening symptoms that persisted despite hemodynamic and echocardiographic-guided LVAD optimization. After heart team review, her anatomy was deemed appropriate for TAVR and she underwent implant of a 26mm Evolut Pro (Medtronic). The procedure was complicated by post-implant complete heart block on POD #4 requiring pacemaker implantation. She was discharged from the hospital, however over the next 3 months had recurrent episodes of low flow alarms that continued despite LVAD speed and medication optimization. A transthoracic echocardiogram did not reveal any abnormalities, although it was unable to visualize the TAVR leaflets. A multiphase 4D CT Angiogram was performed to rule out LVAD outflow graft obstruction, which revealed extensive hypoattenuating leaflet thickening involving all 3 leaflets of the TAVR with absent leaflet motion consistent with thrombosis of the prosthetic valve leaflets (See Figure). She was started on intravenous anticoagulation (unfractionated heparin), but this had to be ceased due to hemodynamically significant GI bleeding requiring multiple transfusions. LVAD speed was also attempted to be increased to minimize risk of aortic valve opening, but this was unable to be continued due to recurrent low flow LVAD alarms. Repeat imaging 3 months later showed continual thrombosis, and she has remained stable while awaiting transplantation. Summary We describe a novel complication of TAVR in LVAD patients. This case highlights the major diagnostic and management dilemmas that should be considered as this management strategy becomes more widespread in this patient population.