Aortic Insufficiency In Patients Research Articles

Management of aortic valve insufficiency in patients with continuous-flow left ventricular assist device: a republication of the review published in Japanese Journal of Artificial Organs.

Since 2011, implantable ventricular assist devices have been a standard treatment for severe heart failure alongside heart transplantation in Japan. However, the limited availability of donors has led to a prolonged wait for transplants, now averaging 1719days, intensifying the issue of aortic insufficiency in patients with continuous flow ventricular assist devices. These devices limit the opening of the aortic valve, leading to sustained closure and increased shear stress, which accelerates valve degradation. Risk factors for aortic insufficiency include having a smaller body surface area, being of advanced age, and the presence of mild aortic insufficiency prior to device implantation. In patients presenting with mild or moderate aortic regurgitation at the time of ventricular assist device implantation, interventions such as aortic valve repair or bioprosthetic valve replacement are performed with the aim of halting its progression. The choice of surgical procedure should be tailored to each patient's individual condition. The management of de novo aortic insufficiency in patients with continuous flow ventricular assist devices remains challenging, with no clear consensus on when to intervene. Interventions for significant aortic insufficiency typically consider the patient's symptoms and aortic insufficiency severity. De novo aortic insufficiency progression in continuous flow ventricular assist devices patients necessitates careful monitoring and intervention based on individual patient assessments and valve condition. This review was created based on a translation of the Japanese review written in the Japanese Journal of Artificial Organs in 2023 (Vol. 52, No. 1, pp. 77-80), with some modifications.

Safety and efficacy of aortic valvuloplasty for de novo aortic insufficiency in patients with a left-ventricular assist device.

Progression of aortic insufficiency during left-ventricular assist device (LVAD) support is a crucial topic. One treatment option is aortic valvuloplasty (AVP); however, there is controversy regarding its safety and efficacy. We investigated the safety and efficacy of AVP using the coaptation stitch method (Park's stitch) performed for de novo aortic insufficiency. Between 2013 and 2020, 175 consecutive patients underwent LVAD implantation, of which 7 patients [men, 2 (28.6%); median age, 55years] underwent late-stage AVP. Two patients underwent AVP within 2weeks, and the remaining six patients underwent AVP 3, 19, 24, 28, 42, and 49months, respectively, after LVAD implantation. Preoperatively, the degree of aortic insufficiency was moderate in 6 (85.7%) patients and severe in 1 (14.3%) patient. AVP was technically successful in 6 (85.7%) patients, while one case of failed plasty was subsequently treated with bioprosthetic valve replacement. A 1-year post-AVP right heart catheterization study revealed a median pulmonary artery wedge pressure of 10.0mmHg. No deaths or heart failure admissions occurred during the follow-up (median, 38.0months). There was no aortic insufficiency in 2 (28.6%) patients; however, trivial AI was observed in 3 (42.8%) patients, and mild AI was observed in 1 (14.3%) patient 2years postoperatively. However, at the 3-year follow-up, two patients developed an increase in AI grade from trivial to mild. AVP using Park's stitch was safe. It is critical to carefully observe the aortic valve during AVP surgery to ensure that AVP is appropriate.

P45: Outcomes Of Percutaneous Transcatheter Interventions For Aortic Insufficiency In Patients With Continuous-Flow Left Ventricular Assist Devices: A Systematic Review

P45: Outcomes Of Percutaneous Transcatheter Interventions For Aortic Insufficiency In Patients With Continuous-Flow Left Ventricular Assist Devices: A Systematic Review

Long-term Outcomes Of Transcatheter Aortic Valve Replacement For Aortic Insufficiency In Patients With Left Ventricular Assist Devices

Long-term Outcomes Of Transcatheter Aortic Valve Replacement For Aortic Insufficiency In Patients With Left Ventricular Assist Devices

Key questions about aortic insufficiency in patients with durable left ventricular assist devices.

The development of the latest generation of durable left ventricular assist devices (LVAD) drastically decreased adverse events such as pump thrombosis or disabling strokes. However, time-related complications such as aortic insufficiency (AI) continue to impair outcomes following durable LVAD implantation, especially in the context of long-term therapy. Up to one-quarter of patients with durable LVAD develop moderate or severe AI at 1 year and its incidence increases with the duration of support. The continuous regurgitant flow within the left ventricle can compromise left ventricular unloading, increase filling pressures, decrease forward flow and can thus lead to organ hypoperfusion and heart failure. This review aims to give an overview of the epidemiology, pathophysiology, and clinical consequences of AI in patients with durable LVAD.

A computational study of aortic insufficiency in patients supported with continuous flow left ventricular assist devices: Is it time for a paradigm shift in management?

De novo aortic insufficiency (AI) following continuous flow left ventricular assist device (CF-LVAD) implantation is a common complication. Traditional early management utilizes speed augmentation to overcome the regurgitant flow in an attempt to augment net forward flow, but this strategy increases the aortic transvalvular gradient which predisposes the patient to progressive aortic valve pathology and may have deleterious effects on aortic shear stress and right ventricular (RV) function. We employed a closed-loop lumped-parameter mathematical model of the cardiovascular system including the four cardiac chambers with corresponding valves, pulmonary and systemic circulations, and the LVAD. The model is used to generate boundary conditions which are prescribed in blood flow simulations performed in a three-dimensional (3D) model of the ascending aorta, aortic arch, and thoracic descending aorta. Using the models, impact of various patient management strategies, including speed augmentation and pharmacological treatment on systemic and pulmonary (PA) vasculature, were investigated for four typical phenotypes of LVAD patients with varying degrees of RV to PA coupling and AI severity. The introduction of mild/moderate or severe AI to the coupled RV and pulmonary artery at a speed of 5,500 RPM led to a reduction in net flow from 5.4 L/min (no AI) to 4.5 L/min (mild/moderate) to 2.1 L/min (severe). RV coupling ratio (Ees/Ea) decreased from 1.01 (no AI) to 0.96 (mild/moderate) to 0.76 (severe). Increasing LVAD speed to 6,400 RPM in the severe AI and coupled scenario, led to a 42% increase in net flow and a 16% increase in regurgitant flow (RF) with a nominal decrease of 1.6% in RV myocardial oxygen consumption (MVO2). Blood pressure control with the coupled RV with severe AI at 5,500 RPM led to an 81% increase in net flow with a 15% reduction of RF and an 8% reduction in RV MVO2. With an uncoupled RV, the introduction of mild/moderate or severe AI at a speed of 5,500 RPM led to a reduction in net flow from 5.0 L/min (no AI) to 4.0 L/min (mild/moderate) to 1.8 L/min (severe). Increasing the speed to 6,400 RPM with severe AI and an uncoupled RV increased net flow by 45%, RF by 15% and reduced RV MVO2 by 1.1%. For the uncoupled RV with severe AI, blood pressure control alone led to a 22% increase in net flow, 4.2% reduction in RF, and 3.9% reduction in RV MVO2; pulmonary vasodilation alone led to a 18% increase in net flow, 7% reduction in RF, and 26% reduction in RV MVO2; whereas, combined BP control and pulmonary vasodilation led to a 113% increase in net flow, 20% reduction in RF and 31% reduction in RV MVO2. Compared to speed augmentation, blood pressure control consistently resulted in a reduction in WSS throughout the proximal regions of the arterial system. Speed augmentation to overcome AI in patients supported by CF-LVAD appears to augment flow but also increases RF and WSS in the aorta, and reduces RV MVO2. Aggressive blood pressure control and pulmonary vasodilation, particularly in those patients with an uncoupled RV can improve net flow with more advantageous effects on the RV and AI RF.

Development of De-Novo Aortic Insufficiency in Patients with Durable Left Ventricular Assist Device Who Were Bridged from Impella Device

<h3>Purpose</h3> As the incidence of INTERMACS I profile patients receiving durable left ventricular assist devices(VADs) increases, there has been a rising use of Impella (Abiomed, Daners, MA) for acute support. While impella allows for end-organ recovery and safe bridging to VAD it has also been associated with the development of de-novo aortic insufficiency (AI) post VAD in small series. We evaluate the incidence and clinical significance of de-novo AI in post VAD patients at our center. <h3>Methods</h3> All patients implanted with durable VAD at our center from 2011-2021 were retrospectively reviewed. Echocardiogram were reviewed prior to VAD implant and 3 months post VAD for the development of de-novo AI. <h3>Results</h3> Forty-eight patients were implanted with Heartmate II or Heartmate 3 (Abbott, Chicago, IL) durable VAD. Twenty-seven patients were bridged with an Impella prior to VAD, while 21 were not. By definition, the Impella-bridged patients were INTERMACS 1 at time of VAD; 24 were male and the mean age was 65.3-years with 62.9% (N=17) with ischemic cardiomyopathy. In this group, 25.9% (N=7) of patients had at least moderate de-novo AI and 48% (N=13) had at least mild de-novo AI at 3 months post VAD. Three of the Impella bridged patients received aortic valve plication during VAD surgery due to significant AI, and at 3 months post VAD, all 3 patients had trace to no AI. Of the 21 patients not bridged with Impella, 17 were INTERMACS 2 and 4 were INTERMACS 3; 18 were male and the mean age was 62.7 years-old, with 61.9%(N=13) having ischemic cardiomyopathy. In this group, 19% (N=4) had at least moderate de-novo AI and 23.8% (N=5) had at least mild de-novo AI a 3 months post LVAD echocardiogram. One patient received prophylactic aortic valve plication during LVAD implantation due to significant baseline AI. No patients required aortic valve intervention post LVAD in the impella-bridged group, while 1 patient required TAVR for AI in the non-impella group. <h3>Conclusion</h3> This retrospective analysis of our single center experience shows that while there is an increased incidence of de-novo AI in VAD patients that are bridged with Impella, the presence of AI may not be clinically significant. By proper afterload reduction and diuresis as well as consideration of aortic plication in patients with at least moderate AI at time of VAD, morbidity of AI can be significantly minimized.

A Computational Study of Aortic Insufficiency in Patients Supported with Left Ventricular Assist Devices

<h3>Purpose</h3> Aortic insufficiency (AI) following left ventricular assist device (LVAD) implantation is common. Speed augmentation to overcome the regurgitant flow (RF) is used but this leads to progressive AI and may have deleterious effects on shear stress (SS) and the right ventricle (RV). <h3>Methods</h3> We employed a closed-loop mathematical model of the cardiovascular system to generate boundary conditions for blood flow simulations performed in a three-dimensional (3D) model of the aortic arch. AI was introduced and the impact of speed augmentation and blood pressure control on SS and RV oxygen consumption (MVO2) were determined in a model with a coupled and uncoupled RV. <h3>Results</h3> Addition of severe AI to the coupled RV at 5500 RPM led to a reduction in net flow from 5.4 L/min (no AI) to 2.1 L/min (severe). Increasing speed to 6400 RPM in the severe AI and coupled RV, led to a 42% increase in net flow and a 16% increase in RF with a nominal decrease of 0.9% in RV MVO2. Blood pressure control with the coupled RV with severe AI at 5500 RPM led to an 81% increase in net flow with a 15% reduction RF and an 8% reduction in RV MVO2 (Fig A). With an uncoupled RV, addition of severe AI at 5500 RPM led to a reduction in net flow from 5.0 L/min (no AI) to 1.8 L/min (severe). Increasing speed to 6400 RPM with severe AI and uncoupled RV increased net flow by 45%, RF by 15% and RV MVO2 by 4.2%. For the uncoupled RV with severe AI, blood pressure control alone led to a 22% increase in net flow, 4.2% reduction in RF and 6.1% reduction in RV MVO2; whereas combined BP control and pulmonary vasodilation led to a 113% increase in net flow, 20% reduction in RF and 41% reduction in RV MVO2 (Fig B). Compared to speed augmentation, blood pressure control consistently resulted in a reduction in SS (Fig C). <h3>Conclusion</h3> Speed augmentation to overcome AI in patients supported by CF-LVAD will augment flow but at the expense of RV MVO2, RF and SS. Aggressive blood pressure control and pulmonary vasodilation can improve net flow with more advantageous effects on the RV and aortic valve integrity.

De Novo Aortic Insufficiency in Patients with Continuous-Flow Left Ventricular Assist Devices: An Updated Systematic Review and Meta-Analysis

<h3>Purpose</h3> Development of <i>de novo</i> aortic insufficiency (AI) or worsening of AI after implant of a continuous-flow left ventricular assist device (CF-LVAD) can be associated with worse post-implant outcomes; however, predictors of prognosis and the long-term outcomes associated with AI have not been well-defined. <h3>Methods</h3> A comprehensive systematic review was conducted through September 2021 using PubMed and Embase. We included studies that reported AI prevalence in patients with CF-LVAD. Patients with prior aortic surgery or prosthesis were excluded. Primary outcome was all-cause mortality in patients with and without AI. Secondary outcome was new AI in patients with close versus open status of the aortic valve. We calculated pooled odds ratio (OR) with 95% confidence intervals (CI) and I² statistic using the random-effects model. <h3>Results</h3> Our systematic review yielded 12 retrospective cohorts, totalizing 2,018 patients who met inclusion criteria for the meta-analysis. Mean age was 56.1 years, 82.5% were male, 42.3% had ischemic cardiomyopathy and 51.4% had CF-LVAD as a bridge to transplant. Follow-up ranged from 6-60 months and the mean duration of LVAD support was at least 314 days. There was no difference in mortality in the groups with and without AR (OR 1.64, 95% CI 0.45-6.0, p=0.45). Closed or open status of aortic valve (AV) was not associated with new AI (OR 2.98, 95% CI 0.82-10.87, p=0.1), <b>Figure</b>. <h3>Conclusion</h3> In this meta-analysis of retrospective studies, new onset AI post CF-LAVD was not associated with increased all-cause mortality. Also, <i>de novo</i> AI was not related to the closed or open status of the AV. Limitations were the small sample size and retrospective model of the studies.

Development of De Novo Aortic Insufficiency in Patients With HeartMate 3

BackgroundDe novo aortic insufficiency (AI) is a common adverse event after continuous-flow left ventricular assist device (LVAD) placement and is associated with morbidity and mortality. This study aims to compare the development of de novo AI between HeartMate 3 (Abbott) and HeartMate II LVAD recipients. MethodsA retrospective review was conducted of clinical characteristics and serial echocardiograms (1 month, 6 months, and 1 year postimplantation) of HeartMate 3 patients implanted between November 2014 and March 2019 and of HeartMate II patients implanted between April 2004 and December 2015 at Columbia University Irving Medical Center. One hundred twenty-two patients were excluded from analysis for a history of aortic valve surgery, concomitant aortic valve surgery with LVAD implant, or more than trace preoperative AI left untreated. De novo AI was defined as development of more than mild AI after LVAD implant. ResultsIncluded in the study were 121 HeartMate 3 patients and 270 HeartMate II patients. After accounting for competing risks of death and transplantation, there was no significant difference in the development of de novo AI by 1 year postimplantation between HeartMate II and HeartMate 3 patients (P = .68). There was no significant difference in severity of AI developed up to 1 year post-implantation between HeartMate II and HeartMate 3 patients. ConclusionsDevelopment of de novo AI is comparable between HeartMate 3 and HeartMate II patients. There is no significant difference in severity of AI between HeartMate II and HeartMate 3 patients.

Immediate and Long-Term Results of Treatment of Aneurysms of Ascending Aorta and Aortic Arch and Substantiation of Tactical Approaches to the Treatment Based on the Obtained Results

Acute aortic dissection is a formidable disease. Its prevalence increases due to the population aging, as well as wider awareness of physicians about this pathology.&#x0D; The aim. To analyze immediate and long-term results of surgical treatment of aneurysms of ascending aorta and aortic arch and to determine optimal methods of correction of these lesions in order to improve the results of surgical treatment.&#x0D; Materials and methods. This was a comparative analysis of immediate and long-term treatment outcomes in 419 patients with aneurysms of ascending aorta and aortic arch. A comparative analysis of the results of treatment of two groups of patients was performed: the comparison group of 157 people operated before 2013, and the main group of 262 patients operated since 2013 using modified methods of aortic surgery.&#x0D; Results. The study showed significant reduction in the left ventricular dilatation according to echocardiography and satisfactory postoperative course in patients of both groups. Patients with valve-sparing aortic prosthetics had better results than those who underwent valve replacement surgery. Hospital mortality decreased from 17.2% to 5.3%.&#x0D; Analysis of long-term results showed that supracoronary aortic prosthetics with aortic valve plasty and elimination of the intimal tear zone make it possible to carry out effective aortic reconstruction. Due to events in the long run, regular lifelong monitoring is required.&#x0D; The analysis also showed that individualized approach to the choice of surgical tactics for the correction of aortic insufficiency in patients with aortic root and ascending aortic pathology allows to achieve comparable results in the immediate and long-term follow-up. Despite the complexity of the applied correction methods, the developed methods of surgical treatment of ascending aortic aneurysm (AAA) and aortic arch aneurysm and methods of protection of brain and visceral organs allowed to keep hospital mortality and the number of complications at the same level corresponding to one of the best world results. This gives hope for a good result in the long-term follow-up.&#x0D; Conclusions. Aneurysm of ascending aorta and aortic arch is a formidable life-threatening disease, and its only non-alternative treatment option is surgery. The optimized approach to the treatment of patients in the main group allowed to obtain better immediate and long-term results of surgical treatment and reduce postoperative complications from 34.4% to 8.4% and hospital mortality from 17.2% to 5.3%. Comparative analysis of long-term results in the studied groups showed more encouraging indicators of quality of life and life expectancy in patients when using modified surgical techniques, protection of the brain and visceral organs. We hope to get a final assessment of these data in the further study of the condition of these patients in the long-term follow-up.

Commentary: "Postoperative Changes in Left Ventricular Systolic Function after Combined Mitral and Aortic Valve Replacement in Patients with Rheumatic Heart Disease" Sang-Mee An, MD, Jae-Sik Nam, MD, Ho Jin Kim, MD, PhD, Hyeun Joon Bae, MD, Ji-Hyun Chin, MD, PhD, Eun-Ho Lee, MD, PhD, In-Cheol Choi, MD, PhD.

It is an elegant albeit limited study reporting effects of pre op LVEF on long term results in patients with RHD undergoing DVR. Study includes 146 patients out of 201 who underwent DVR in the study period. Although all had some improvement immediate post op, those with preserved ejection fraction (EF) and smaller left ventricles regardless of type of prostheses used, surgical techniques (partial or full Subvalvular Apparatus Preservation), had more sustained improvement after 3-4 years than those with lower EF and more dilation. It can be partially explained by more prevalence of aortic insufficiency in patients with pre op lower EF <50 and dilation (average left ventricular end systolic dimension 49 vs. 32 mm in EF >50). There are myocardial factors which also play a part, those with abnormal left ventricle (LV) function have more extensive loss of myofibrils either due to disproportion of mitochondria-to-myofibril ratio or myofibrillar degeneration exhibiting the extent RHD involves myocardium. Structural adaptation may not all be just a result of hemodynamic abnormalities in these patients. The recommendation that surgical intervention should occur before the LV starts to dilate or EF drops is well founded and would be impactful in the developing world, an estimated 250,000 deaths occur annually worldwide and 10.5 million disability adjusted life years due to RHD, mostly in young people.

Recurrent aortic insufficiency after emergency surgery for acute type A aortic dissection with aortic root preservation

ObjectivePatients with acute type A aortic dissection demonstrate a wide range of aortic insufficiency. Outcomes after valve resuspension and root repair are not well studied in the long term. We evaluated the long-term effects of preoperative aortic insufficiency in patients undergoing emergency root-preserving surgery for acute type A aortic dissection. MethodsFrom 2002 to 2017, 558 of 776 patients with acute type A aortic dissection underwent native aortic valve resuspension and root reconstruction. Patients were stratified into 4 groups by preoperative aortic insufficiency grade (n = 539): aortic insufficiency less than 2+ (n = 348), aortic insufficiency = 2+ (n = 72), aortic insufficiency = 3+ (n = 49), and aortic insufficiency = 4+ (n = 70). Multivariable ordinal longitudinal mixed effects and multi-state transition models were used to assess risk factors for recurrent aortic insufficiency. ResultsThe prevalence of cardiogenic shock in patients presenting with preoperative aortic insufficiency less than 2+, 2+, 3+, and 4+ was 53 of 348 (15.2%), 12 of 72 (16.7%), 10 of 49 (20.4%), and 24 of 70 (34.3%), respectively (P = .002). Postoperatively, 94.0% of patients had aortic insufficiency 1+ or less at discharge. Operative mortality was 34 of 348 (9.8%), 10 of 72 (13.9%), 6 of 49 (12.2%), and 12 of 70 (17.1%) (P = .303). In an ordinal mixed effects model, preoperative aortic insufficiency was associated with more severe postoperative aortic insufficiency. The multi-state transition model demonstrated that severe aortic insufficiency was associated with progression from no to mild aortic insufficiency (hazard ratio, 2.14; 95% confidence interval, 1.35-3.38), and progression from mild to moderate aortic insufficiency (hazard ratio, 5.70; 95% confidence interval, 1.88-17.30). ConclusionsPreoperative aortic insufficiency is an important predictor of recurrent aortic insufficiency in patients undergoing valve resuspension with root reconstruction for emergency acute type A aortic dissection repair. Increased echocardiographic surveillance for recurrent aortic insufficiency may be warranted in this cohort.

Development of De Novo Aortic Insufficiency in Patients with HeartMate 3

Aortic insufficiency (AI) is common following continuous flow left ventricular assist device (CFLVAD) and is associated with morbidity and mortality. This study aims to assess the incidence of de novo AI in HeartMate 3 (HM 3) LVAD recipients and compare the outcomes with HeartMate II (HM II) patients. A retrospective review was conducted of clinical characteristics and serial echocardiograms (1 month, 6 months, and 1 year post implant) of 151 HM 3 patients implanted between Nov. 2014 and March 2019, as well as of 270 HM II patients implanted between April 2004 and Dec. 2015 at our center. Patients (n=30) were excluded from analysis for a history of aortic valve (AV) surgery, concomitant AV surgery with LVAD implant, or more than trace preoperative AI left untreated. De novo AI was defined as more than mild AI. In the HM 3 cohort, mean age was 58 ± 12 and 84% were male. 74% received HM 3 as destination therapy. Incidence and degree of de novo AI in each group is summarized in Figure 1. 4 patients were readmitted due to significant AI and heart failure symptoms. Cumulative incidence curves showed that the probability of de novo AI at 1 year was 8.4% in the HM 3 cohort vs. 13% in the HM II cohort (Figure 2, p=0.29). In both cohorts, patients who had AV opening on echocardiogram at 1 month post implant were significantly less likely to develop de novo AI (100% freedom from de novo AI at 1 year for HM 3 with open AV vs. 84% for HM 3 with closed AV, 97% for HM II with open AV vs. 76% for HM II with closed AV). The incidence of de novo AI is low and comparable between HM 3 and HM II patients at our center. AV opening at 1 month post implant appears to be protective of this complication.

AORTIC VALVE REPLACEMENT IN PATIENT WITH FUNCTIONING CORONARY ARTERY BYPASS GRAFTS

We report the clinical case of aortic valve replacement for severe aortic insufficiency in patient who previously was subjected to coronary bypass grafting, with functioning grafts, including internal thoracic artery graft. The procedure was performed from the upper ministernotomy with peripheral (femoral) cardiopulmonary bypass.

Management of aortic insufficiency in patients with left ventricular assist device ̶ a retrospective analysis

Background&#x0D; Aortic insufficiency is increasingly recognized as a complication of left ventricular assist device (LVAD) support and may lead to clinical decompensation requiring correction. This article describes experiences in managing patients presenting with concomitant aortic insufficiency and with de novo aortic insufficiency following left ventricular assist device implantations.&#x0D; Methods&#x0D; All patients undergoing LVAD implantation between 2012 and 2014 were included in this retrospective analysis if aortic valve insufficiency was present on implantation or newly developed (de novo) after implantation. Moderate to severe aortic valve insufficiency was corrected at implantation.&#x0D; Results&#x0D; The data of 39 patients were included. At the time of LVAD implantation, moderate to severe aortic valve insufficiency was present in 3 patients and was corrected by bioprosthetic valve replacement (2 patients) and by bioprosthetic valve replacement associated with ascending aorta with hemi arch replacement with a graft due to ascending aortic aneurysm (one patient). Four patients developed moderate to severe aortic insufficiency after LVAD surgery. Treatment with conservative medical management was successful in 3 patients. One patient underwent transcatheter aortic valve occlusion using an Amplatzer closure device after failure of medical management.&#x0D; Conclusions&#x0D; Concomitant aortic valve replacement with LVAD implantation is a safe and viable option in managing aortic valve insufficiency. De novo aortic insufficiency may lead to recurrent heart failure and presents a clinical treatment challenge following successful LVAD support; the most appropriate and effective treatment option awaits definition.

The Hemodynamic Effects of Aortic Insufficiency in Patients Supported With Continuous-Flow Left Ventricular Assist Devices

BackgroundThe impact of aortic insufficiency (AI) on the morbidity and mortality of left ventricular assist device (LVAD) patients remains controversial. This study's aim was to assess the hemodynamics of LVAD patients with at least mild AI, at baseline and in response to device speed changes. Methods and ResultsAsymptomatic LVAD patients were prospectively enrolled and underwent a hemodynamic and echocardiographic ramp study. Hemodynamics at rest and in response to device speed changes were compared between patients with at least mild AI at their baseline speed and patients without AI. Fift-five patients were enrolled in the study, and 42% had AI. The AI group had higher baseline central venous pressure (11 ± 5 vs 8 ± 5 mm Hg; P = .03), higher pulmonary capillary wedge pressure (PCWP) (16 ± 6 vs 12 ± 6 mm Hg; P = .02) and lower pulmonary artery pulsatility index (PAPI) (2.3 ± 1.3 vs 3.6 ± 2.4; P = .01). Cardiac index (CI) increased and PCWP decreased in both groups by similar degrees during the ramp study. AI worsened in 78% of patients during the ramp study. ConclusionsLVAD patients with at least mild AI have increased filling pressures and reduced PAPI. Normalization of filling pressures can be achieved by increasing LVAD speed; however, this concomitantly worsens AI severity. The long-term hemodynamic consequences of this approach are unknown.

(1344) - Transcatheter Aortic Valve Replacement Management of Aortic Insufficiency in Patients with Left Ventricular Assist Device Support

Left ventricular assist device (LVAD) use either as bridge-to-transplantation or as destination therapy increases survival of stage D heart failure patients. Aortic insufficiency (AI) is one of the major complications that compromise LVAD efficiency. Trans-catheter aortic valve replacement (TAVR) is one of the alternatives in patients that are prone to high risk for surgical replacement of the valve.

Transcatheter aortic valve repair for management of aortic insufficiency in patients supported with left ventricular assist devices

The development of new aortic insufficiency after a period of support with a left ventricular assist device can result in progressive heart failure symptoms. Transcatheter aortic valve repair can be an effective treatment in selected patients, but the lack of aortic valve calcification can result in unstable prostheses or paravalvular leak. We describe a technique of deploying a self-expanding CoreValve (Medtronic, Minneapolis, MN, USA) into the aortic annulus, followed by a balloon-expandable SAPIEN-3 (Edwards, Irvine, CA, USA).

Prognostic Importance of Diastolic Dysfunction in Relation to Post Procedural Aortic Insufficiency in Patients Undergoing Transcatheter Aortic Valve Replacement.

We sought to examine whether baseline diastolic dysfunction (DD) is associated with increased mortality in patients who develop aortic insufficiency (AI) after transcatheter aortic valve replacement (TAVR). Significant post-TAVR AI is associated with increased mortality, likely secondary to adverse hemodynamics secondary to volume overload and decreased LV compliance from chronic pressure overload. However, the effect of baseline DD on outcomes of patients with post-TAVR AI has not been studied. A total of 195 patients undergoing TAVR were included in the study. Patients with moderate-to-severe mitral stenosis, prior mitral valve replacement or atrial fibrillation were excluded. DD was classified at baseline by a 2-step approach as recommended by the American Society of Echocardiography while AI was evaluated 30 days post-TAVR. Follow up data up to 2 years post-TAVR was used in survival analysis. Patients with severe baseline DD who developed ≥mild post-TAVR AI had increased mortality compared to all other patients (HR = 3.89, CI: 1.76-8.6, P = 0.001), which remained significant after adjusting for post-TAVR AI, pre-TAVR AI, baseline mitral regurgitation, ejection fraction, pulmonary artery pressure, creatinine clearance and history of stroke. Even mild post-TAVR AI may have a negative impact on outcomes of patients with underlying severe DD. © 2016 Wiley Periodicals, Inc.