Progressive Aortic Insufficiency 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.

Fluid mechanics of aortic valve incompetence in the dilated left ventricle

Introduction: Aortic insufficiency (AI) occurs when the aortic valve fails to close completely, allowing backward blood flow into the left ventricle (LV). The progression of AI can lead to ventricular dysfunction and congestive heart failure, setting off a self-perpetuating cycle that worsens these conditions. This study employed models of repeatable and reversible AI within a simulated circulatory loop to analyze vortex dynamics, AI parameters, and gain insights into the efficiency of ventricular washout.Method: A transparent silicone model of an LV with an ejection fraction of 17% served as the baseline, simulating a condition without AI. Mild, moderate, and severe AI were induced using 3D-printed stents, obstructing the complete closure of the aortic valve while allowing unimpeded forward blood flow. Midplane velocity fields were analyzed to compute AI and vortex properties, energy dissipation rate, blood residence time, and shear activation potential.Results and discussion: With increasing AI severity, the regurgitant jet expanded, impeding the development and trajectory of mitral inflow. The inefficiency in fluid transport became apparent through a declining ratio of total kinetic energy rate to energy dissipation rate and an increasing residence time. Impaired ventricular washout resulted in the accumulation of fluid with elevated shear activation potential in the LV. These findings suggested that AI progressively induces abnormal intraventricular flow, heightening the thromboembolic risk in heart failure patients. The study also advocates for the potential application of mock circulatory system to explore the effects of various AI configurations, especially when combined with other cardiac implants like artificial heart valve or left ventricular assist device.

Abstract 18152: Clinical Impact and Mechanism of De Novo Aortic Insufficiency During Percutaneous Ventricular Assist Device Support for Cardiogenic Shock

Introduction: Recently, percutaneous ventricular assist device (p-LVAD) has been widely applicable for cardiogenic shock. Clinically significant aortic insufficiency (AI) is contraindication for p-LVAD, nevertheless p-LVAD itself can cause de novo AI (dAI) during the support. However the detail of dAI during p-LVAD support was not fully investigated. The aim of this study was to evaluate the clinical impact of AI during p-LVAD support and also investigate the mechanism and risk factor of dAI. Methods: Seventy-seven consecutive patients who underwent p-LVAD support (average age 66.7 years, Impella CP/2.5 in 65 and 5.5/5.0 in 12 cases) from 2018 to 2022 were retrospectively evaluated. The average support periods was 8.0±6.9 days. dAI was defined as development of AI ≥ moderate during p-LVAD support. Aortic valve pathology was examined using autopsy specimens in eight patients. Results: Three patients had AI ≥ moderate before p-LVAD support and underwent surgical intervention (AVR in 2 and AV repair in 1) during p-LVAD support. dAI was observed in 8 patients (10.3%, moderate in 7 and severe in 1). Moderate dAI in four of these patients improved after cardiac recovery and weaning of p-LVAD support. However, in 3 other patients with dAI ≥ moderate developed hemodynamic instability and deceased due to heart failure. In only a patient, moderate dAI remained after p-LVAD weaning with stable hemodynamics. Progression of AI after p-LVAD removal was not observed in all patients. In-hospital mortality was higher in the patient with dAI (75.0 vs. 47.8%, p=0.14). Pathological evaluation revealed hemorrhagic change at LV side of aortic valve with hemosiderin-laden macrophages in 3 autopsy specimens, which suggested contact of p-LVAD catheter. The univariate analysis identified mild AI before p-LVAD support as independent risk factor for dAI (Odd ratio 5.5, 95%CI 0.074-0.45, p<0.001). Conclusions: Our study demonstrated that de novo AI frequently occurred during p-LVAD support and had a negative impact on hemodynamics and prognosis. Interference with aortic valve by the p-LVAD catheter may cause and exacerbate AI, even in the cases with pre-existing mild AI. Surgical intervention is essential to improve hemodynamics for severe and permanent AI during p-LVAD support.

Abstract 17322: Closing the Loop: Use of Amplatzer PFO Occluder Device in Case of LVAD-Associated Aortic Insufficiency

Description of Case: A 72-year-old woman with destination therapy Heartmate 3 left ventricular assist device (LVAD) presented with NYHA Class III symptoms. Review of her echocardiograms since LVAD implantation revealed progressive central aortic insufficiency (AI) with subsequent LV dilatation, managed with reduction in LVAD speed. Patient declined surgical aortic valve replacement and/or repair. After a multidisciplinary discussion, the patient opted to pursue percutaneous aortic valve closure. Cardiac CT demonstrated no aortic valve thrombus and identified appropriate anatomy for closure with an 18x25 mm Amplatzer PFO Occluder device (Graphic 1). Preoperative TEE revealed LV ejection fraction of 15% with moderate to severe AI and fibrosis of the aortic valve commissures with no aortic valve movement. The aortic valve was closed with the Amplatzer PFO Occluder with an 18mm disk that sat on the LV side of the aortic valve within the AV annulus and the 25mm disk sitting on the aortic side of the aortic valve within the sinus of Valsalva. TEE and intracardiac echocardiography demonstrated excellent device placement with two residual trace AI jets at the non-left and left-right commissure. Following LVAD speed increase, the degree of AI remained unchanged and she was discharged with improved symptoms. Discussion: Moderate-severe AI develops in about 15-25% of patients within 1 year of LVAD implantation. There are previous reports of LVAD-associated AI closure with an Amplatzer cribiform device. We describe the first known use of the Amplatzer PFO Occluder device for the management of LVAD-associated AI. While transcatheter aortic valve replacement (TAVR) is an attractive option to treat LVAD-associated AI, securing the transcatheter heart valve in the absence of calcifications remains a challenge.

Transcatheter aortic valve replacement 23 years after heart transplant for aortic insufficiency

BackgroundClinicians continue to expand the availability of transcatheter aortic valve replacement (TAVR) for patients who historically would have been ineligible for surgical aortic valve replacement. Historically, reoperative aortic valve surgery after transplant was immensely complicated and high risk due to the repeat sternotomy approach, and the immunosuppression in transplant patients. As heart transplant patients continue to live longer, patients are beginning to develop novo aortic pathology of the transplanted organ. In these patients, TAVR may be a valuable rescue therapy for those with de-novo aortic valve disease.Case presentationHere, we present a single case of a 70-year-old man with a history of heart transplant 23 years prior complicated by severe sternal infection and subsequent removal of his sternum. Additionally, this patient had a recent history of kidney transplant due to renal cell carcinoma necessitating nephrectomy. He subsequently developed progressive symptomatic aortic insufficiency and underwent a successful TAVR to treat his new aortic disease.ConclusionsTo our knowledge, this represents only the second case report of TAVR for severe aortic insufficiency and one of the first reports of TAVR in a multiple organ recipient. TAVR may represent an important rescue therapy for post-transplant valve pathologies instead of high-risk reoperative surgical aortic valve replacement.

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.

Transcatheter closure of a ruptured sinus of valsalva: a systematic review of the literature.

Ruptured sinus of Valsalva (RSOV) is a rare pathology, and current data regarding its symptoms, anatomy, associated pathologies, and appropriate therapeutic approaches are scarce. Transcatheter closure (TCC) has been performed in multiple cases; however, the information on its success rate and complications is limited. Two independent reviewers performed an advanced search based on inclusion criteria on Scopus, PubMed, and Embase from January 1985 through July 2022. The main search terms were "Sinus of Valsalva", "Rupture/Aneurysm", and "Transcatheter/Catheter/Device". Totally, 1,017 relevant articles from the 3 databases were retrieved. After the final review and appraisal, 94 articles describing 407 patients who underwent the TCC of RSOV were included. Males comprised 65% of the studied patients, and the average age was 34.5 years. The total success rate of TCC was 95.6%. Forty-nine patients (12%) developed complications, the most significant of which were sustained residual shunts in 7 patients (1.7%), substantial new onset or progression of aortic insufficiency in 6 (1.5%), and RSOV recurrence in 6 (1.5%). Post-interventional mortality was reported in only 2 patients (0.5%). The present study is the first systematic review of available data regarding the TCC of RSOV principally comprising case series and case reports. Although TCC seems a good option, precise patient selection is mandatory.

Long-Term Results of Congenital Aortic Stenosis Treatment in the Era of Percutaneous Balloon Valvuloplasty: Up to 33 Years Follow-Up.

Background The goal of this study was to evaluate long-term results of percutaneous balloon valvuloplasty (BVPL) used exclusively for initial management of congenital aortic stenosis in children. Methods and Results A total of 409 consecutive pediatric patients (134 newborns, 275 older patients) who underwent BVPL as initial treatment of aortic stenosis in a single nationwide pediatric center were subjected to a retrospective follow-up study. The resulting follow-up time reached a median of 18.5 (interquartile range, 12.2-25.1) years. Successful BVPL was defined by residual Doppler gradient <70/40 (systolic/mean) mm Hg. The primary end point was death; secondary end points included any valve reintervention, balloon revalvuloplasty, any aortic valve surgery, and aortic valve replacement, respectively. BVPL effectively reduced the peak and mean gradient both immediately and at the latest follow-up (P<0.001). There was significant procedure-related progression of aortic insufficiency (P<0.001). Higher aortic annulus z score was predictive for severe aortic regurgitation (P<0.05) and lower z score for insufficient gradient reduction (P<0.05). The actuarial probability of survival/survival free from any valve reintervention was 89.9%/59.9%, 85.9%/35.2%, and 82.0%/26.7% at 10, 20, and 30 years after first BVPL, respectively. Left ventricular dysfunction or arterial duct dependency as the indication for BVPL was predictive of both worse survival and survival free from any reintervention (P<0.001). Lower aortic annulus z score and lower balloon-to-annulus ratio were predictive of a need for revalvuloplasty (P<0.001). Conclusions Percutaneous BVPL provides good initial palliation. In patients with hypoplastic annuli and left ventricular or mitral valve comorbidity, the results are less favorable.

Concomitant or late aortic valve intervention and its efficacy for aortic insufficiency associated with continuous-flow left ventricular assist device implantation.

Moderate to severe aortic insufficiency (AI) in patients who underwent continuous-flow left ventricular assist device (CF-LVAD) implantation is a significant complication. According to the INTERMACS registry analysis, at least mild AI occurs in 55% of patients at 6 months after CF-LVAD implantation and moderate to severe AI is significantly associated with higher rates of re-hospitalization and mortality. The clinical implications of these data may underscore consideration of prophylactic aortic valve replacement, or repair, at the time of CF-LVAD implantation, particularly with expected longer duration of support and in patients with preexisting AI that is more than mild. More crucially, even if a native aortic valve is seemingly competent at the time of VAD implantation, we frequently find de novo AI as time goes by, potentially due to commissural fusion in the setting of inconsistent aortic valve opening or persistent valve closure caused by CF-LVAD support, that alters morphological and functional properties of innately competent aortic valves. Therefore, close monitoring of AI is mandatory, as the prognostic nature of its longitudinal progression is still unclear. Clearly, significant AI during VAD support warrants surgical intervention at the appropriate timing, especially in patients of destination therapy. Nonetheless, such an uncertainty in the progression of AI translates to a lack of consensus regarding the management of this untoward complication. In practice, proposed surgical options are aortic valve replacement, repair, closure, and more recently transcatheter aortic valve implantation or closure. Transcatheter approach is of course less invasive, however, its efficacy in terms of long-term outcome is limited. In this review, we summarize the recent evidence related to the pathophysiology and surgical treatment of AI associated with CF-LVAD implantation.

Abstract 14995: Outcomes of Transcatheter Aortic Valve Replacements in Patients With Left Ventricular Assist Device

Background: The development or progression of aortic insufficiency (AI) to moderate to severe in patients with left ventricular assist devices (LVADs) for end stage heart failure has been increasingly recognized and occurs in 30-40% of patients with continuous flow LVADs. This can lead to reduced efficiency of the LVAD and is associated with increased rates of hospitalizations and mortality. Up to 30% of LVAD patients with moderate to severe AI require surgical valve closure or replacement, which is high risk. More recently, case reports demonstrated transcatheter aortic valve replacement (TAVR) is feasible in LVAD patients with symptomatic AI, but there is a lack of large-scale study. Methods: National Readmission Databases (NRD) from 2015 to 2019 were used to identify hospitalizations with International Classification of Diseases-9th Revision and International Classification of Diseases-10th Revision procedural codes for TAVR in patients with and without LVAD. The outcomes of interest were mortality and 30-day readmission rate. Results: We identified a total of 245,176 TAVR hospitalizations. Among them, 146 (0.001%) had LVAD. LVAD patients undergoing TAVR were significantly younger (mean age 67.5 years vs. 79.6 years; P: &lt;0.001) and had more comorbidities such as arrhythmias, peripheral vascular disease, chronic kidney disease, and anemia. On univariate analysis, LVAD patients demonstrated higher mortality (OR 4.88; 95% CI 2.17 - 11.02; P: &lt;0.001), however, multivariate analysis showed this trend to be insignificant (OR 1.91; 95% CI 0.74-4.96; P= 0.184). Overall, patients with LVAD undergoing TAVR did have an increased length of stay and higher cost of hospitalization (P&lt;0.001). We have witnessed the increasing trend of TAVR use in LVAD patients in the last five years (P: 0.009). After the propensity match, the 30-day readmission rate was not statistically significant (26.5 vs. 25%, P: 0.84). Conclusion: In our analysis, the mortality and 30-day readmission of LVAD patients undergoing TAVR were not significantly higher compared to non-LVAD patients. However, this finding may be limited due to the relatively small number of patients. Overall, this study indicates that TAVR may be considered in the appropriately selected LVAD patients.

Flow dynamics during the HeartWare HVAD to HeartMate 3 exchange: A computational study assessing differential graft lengths and surgical techniques.

Flow dynamics during the HeartWare HVAD to HeartMate 3 exchange: A computational study assessing differential graft lengths and surgical techniques.

When a Single Choice Impacts a Single Ventricle: Paracorporeal Pediatric VAD Support at 544 Days

<h3>Purpose</h3> Caring for single ventricle ventricular assist devices (SVAD) comes with challenging anatomy, management, and complexities in decision-making for the entire care team, including the family. <h3>Methods</h3> Our case highlights the ethical and medical/surgical challenges of supporting an SVAD patient and insights uncovered during a prolonged in-hospital course. <h3>Results</h3> A 3 yr old, 17 kg decompensating hemi-Fontan was admitted from an outside hospital and urgently placed on ECMO. She was transitioned to an extracorporeal continuous flow "biventricular" VAD (BiVAD) (Figure). Due to HLA sensitization, transplantation without desensitization was not feasible. Options presented to the family included: desensitization, conversion to durable BiVAD support, compassionate deactivation, or continuation of current support. The family declined the first three options in favor of enhancing quality of life on current support, a value which persists throughout their hospitalization. During her 544-hospital day course, most of which has been spent on the cardiology ward, we have encountered numerous challenges of daily living along with a significant amount of moral distress from staff. Specific challenges have included living as "normal" a life as possible, optimizing communication among staff and with family, establishing risk assessments for activities under novel circumstances, and navigating moral and ethical distress. Despite an early period of respiratory insufficiency and progressive aortic insufficiency, she is happy and enjoys frequent visits from family, including a new sibling born during her stay, and relationships with staff. <h3>Conclusion</h3> Clinical success with a novel support strategy revealed challenges for the long-term inpatient mechanical support patient, family, and staff caring for them. Our experience identifies the need for a comprehensive, goal-based approach to patient management moving the care team, including the family, to reframe the definition of success.

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.

Progression of aortic insufficiency with durable mechanical support.

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.

Progression of aortic valve insufficiency during centrifugal versus axial flow left ventricular assist device support.

Long-term left ventricular assist device (LVAD) support can cause accelerated progression of aortic insufficiency (AI). The MOMENTUM trial has led to increased use of the HeartMate 3 (HM3) LVAD, due to greater hemocompatibility. However, the differential effect on the rate of progression of AI during HM3 support versus HeartMate 2 (HM2) has not been extensively studied. This analysis compares the rates of progression to moderate or severe AI (MSAI) comparing a cohort of patients supported with the HM2 versus HM3. A retrospective review was performed on all consecutive patients implanted with HM2 or HM3 between May 2005 and June 2020. Follow-up time was limited to the first 6 years after LVAD implantation. Demographics and 4005 echocardiograms were assessed for 536 HM2 and 300 HM3 patients. The primary end point was progression to MSAI. Univariable and multivariable Cox proportional hazard regression and landmark analyses were performed. Progression to MSAI was greater in the HM2 (17%) versus HM3 (9.9%) cohort. On the univariable analysis, the hazard ratio for HM3 was 0.581 (95% confidence interval 0.370-0.909, P = 0.02) whereas on multivariable analysis hazard ratio was 0.624 (95% confidence interval 0.386-1.008, P = 0.0537). Preoperative AI, female sex and body surface area <2 were significantly associated with progression to MSAI. Landmark analysis suggests that LVAD type has the most significant effect on progression to MSAI between 1 and 2 years post-implantation. Current practice strategies achieved low rates of progression to MSAI. Preoperative AI, female sex and body surface area <2 were the most important predictors of progression to MSAI. Pump type appears to be of secondary importance.

Role of Balloon Aortic Valvuloplasty in the Management of Aortic Stenosis

Balloon aortic valvuloplasty (BAV) provides an excellent alternative to surgical intervention and has become the preferred intervention for initial palliation for aortic stenosis in neonates, infants, children, adolescents, and young adults. The elderly patients with calcific aortic stenosis do not benefit from BAV. With the exception of neonates, most patients can be discharged home within 24-hours of the procedure. Although there is definitive evidence for pressure gradient relief immediately after as well as at follow-up and postponement of surgical intervention following BAV, the progression of aortic insufficiency at late follow up remain a major concern. In the neonatal population, severe aortic insufficiency may develop requiring surgical intervention. Despite these limitations, balloon aortic valvuloplasty is currently considered as therapeutic procedure of choice in the management of congenital aortic stenosis in the pediatric and young adult population. Careful follow-up to detect recurrence of stenosis and development of significant aortic insufficiency is recommended.

Can the intermittent low-speed function of left ventricular assist device prevent aortic insufficiency?

Aortic insufficiency (AI) is known to associate with a persistently closed aortic valve during continuous-flow ventricular assist device support. Some devices carry an intermittent low-speed (ILS) function, which facilitates aortic valve opening, but whether this function prevents AI is unknown. In this study, the Jarvik 2000 device, which is programmed to reduce the pump speed each minute for 8 s, was chosen to examine this potential effect. Prospectively collected data of 85 heart transplant-eligible Jarvik 2000 recipients who met the study criteria (no pre-existing AI and aortic valve surgery) were retrospectively analyzed for the incidence, correlating factors, and clinical outcomes of de novo AI. All data were provided by the Japanese Registry for Mechanically Assisted Circulatory Support. De novo AI occurred in 58 patients, 23 of whom developed at least moderate AI during a median support duration of 23.5 months. Freedom from moderate or greater AI was 84.4%, 66.1% and 60.2% at 1, 2 and 3 years, respectively. Multivariate analyses revealed that progressive AI was correlated with decreased pulse pressure after implantation (hazard ratio 1.060, 95% confidence interval 1.001–1.127, p = 0.045). No correlation was found for mortality or other adverse events, including stroke, bleeding, infection, pump failure, hemolysis, and readmission. The benefit of the Jarvik 2000′s current ILS mode against AI appears to be minimal. However, in this limited cohort where all recipients underwent implantation as a bridge to transplantation, the impact of de novo progressive AI on other clinical adversities was also minimal.

Aortic Insufficiency Causes Symptomatic Heart Failure during Left Ventricular Assist Device Support.

De novo aortic insufficiency is often documented during long-term left ventricular assist device (LVAD) support, despite the absence of aortic insufficiency at the time of LVAD implantation. However, whether aortic insufficiency affects long-term mortality and symptomatic heart failure in LVAD-supported patients remains controversial. We aimed to examine whether aortic insufficiency development influenced mortality and symptomatic heart failure following LVAD implantation. Fifty-three patients who underwent durable LVAD implantation between January 1, 2008 and April 31, 2017 were retrospectively examined in a single center institute. After discharge, we performed the echocardiographic examination in accordance with the Japanese registry for the mechanically assisted circulatory support protocol. Aortic insufficiency was graded on an interval scale (severe = 4, moderate = 3, mild = 2, trivial or none = 1). Kaplan-Meier estimates for long-term mortality at the follow-up were generated. We used a logistic regression model to identify risk factors for symptomatic heart failure. The overall median duration of LVAD support was 856.3 ± 430.8 days (range, 12-1,744 days). We did not observe a significant difference in long-term mortality in patients with aortic insufficiency ≥ 3 grade compared with patients with aortic insufficiency < 3 grade (P = 0.767; log-rank). Aortic insufficiency was associated with an increased risk for heart failure event after discharge (odds ratio, 4.12; confidence interval, 1.48-16.93; P = 0.005). Aortic insufficiency was an independent risk factor for symptomatic heart failure and was not associated with long-term mortality. Aortic insufficiency progression was associated with symptomatic heart failure.

Impact of worsening of aortic insufficiency during HeartMate 3 LVAD support.

Aortic insufficiency remains a difficult to treat and highly morbid condition even in the era of HeartMate 3 left ventricular assist devices (LVADs). The prognostic nature of the longitudinal progression of aortic insufficiency, however, remains unknown. We prospectively collected data on patients who received HeartMate 3 LVAD implantation, who had assessments of aortic insufficiency using a novel Doppler echocardiography obtained at outflow graft at three (baseline) and 6 months postimplant. Patients with moderate or greater aortic insufficiency at baseline were excluded. The risk of aortic insufficiency progression on 1-year death and readmission for heart failure was investigated. In total, 41 patients (median 51years old and 29 males) were included. All patients had less than moderate aortic insufficiency at baseline. Of them, 22 patients had worsening aortic insufficiency for 3 months following baseline assessments, which was associated with a significantly higher risk of 1-year death or heart failure readmission rate (41% vs. 11%, P=.023) with a hazard ratio of 3.24 (95% confidence interval 1.02-18.5, P=.038) adjusted for device speed at baseline and destination therapy indication. In patients with HeartMate 3 LVADs, progressive aortic insufficiency may be associated with a higher risk of 1-year death or readmission for heart failure. Close monitoring of patients with baseline aortic insufficiency should be considered as a measure to risk-stratify those for future adverse events.

Continuous-Flow Left Ventricular Assist Devices and the Aortic Valve: Interactions, Issues, and Surgical Therapy.

Concomitant valve disease is common in patients undergoing continuous-flow left ventricular assist device (CF-LVAD) implantation. In this review, we characterize the epidemiology and management of aortic valve disease following CF-LVAD. Studies suggest that 20-40% of patients have mild or greater aortic insufficiency (AI) at baseline and that AI progresses following CF-LVAD implantation. AI, either pre-existing or de novo, can have deleterious effects on LVAD efficacy and clinical outcomes. Surgical methods to correct AI in patients supported with CF-LVAD include central oversewing of the aortic valve, complete closure of the aortic valve, patch closure of the ventriculo-aortic junction, or aortic valve replacement with a bioprosthesis. Transcatheter options have recently emerged as feasible modalities to address AI. CF-LVADs contribute to the progression of aortic insufficiency (AI) and its development de novo. Prompt recognition, assessment, and treatment are important. Aortic valve repairs and replacements, now including TAVR, are the primary surgical methods to correct AI.