Abstract
Purpose Concomitant surgical intervention for valvular disease in patients with continuous-flow left ventricular assist device (cLVAD) is controversial. In this study, we evaluated strategies for valvular disease in cLVAD patients treated at our institution. Methods We reviewed 191 consecutive patients [126 males (66%), mean age 43 years] who underwent cLVAD implantation between 2005 and 2018. The devices were Jarvik 2000 in 45 (21%), Heart Mate II in 74 (35%), Dura Heartin 42 (20%), EVAHEART in 33 (16%), and HVAD in 16 (8%) patients. The severity of aortic insufficiency (AI), mitral regurgitation (MR), and tricuspid regurgitation (TR) was classified as none, trivial, mild, moderate, or severe using echocardiography , with moderate and severe defined as significant. Results The mean cLVAD support duration was 701days. Preoperative echocardiography showed significant AI in 3 (2%), MR in 67 (39%), and TR in 50 (30%) patients. Concomitant valve surgery was performed in 20 (10%) for AI, 13 (7%) for MR, and 49 (26%) for TR. In patients who did not undergo concomitant valve surgery, significant MR or TR was immediately decreased after cLVAD implantation and sustained in late follow-up (MR: preoperative 40%, postoperative 10%; late follow-up 6%; TR: 16%, 4%, 5%, respectively), whereas significant AI was gradually increased (0%, 7%, 27%, respectively) and 10 patients required reoperation for AI. The rate of freedom from severe AI was 93±3%, from moderate AI was 65±5%, and from mild AI was 14±3% (Figure).Multivariable analysis revealed that severe AI [hazard ratio (HR) 3.4, 95% confidence interval (CI) 1.1-8.8, p=0.03] and severe TR (HR 8.6, 95%CI 1.3-31, p=0.03) were associated with reoperation, while severe AI (HR 7.5, 95%CI 1.5-34, p=0.02) was associated with readmission for heart failure. Conclusion Our current strategy of concomitant valve surgery for MR and TR seems to be acceptable, while that for AI should be carefully considered.
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