Natural history and clinical effect of aortic valve regurgitation after left ventricular assist device implantation.

Aortic valve regurgitation reduces left ventricular assist device mechanical efficiency. Evidence has also suggested that left ventricular assist device implantation can induce or exacerbate aortic valve regurgitation. However, this has not been compared with aortic valve regurgitation progression in a nonsurgical end-stage heart failure population. Furthermore, its clinical effect is unclear. We sought to characterize the development and progression of aortic valve regurgitation in left ventricular assist device recipients and to identify its clinical effect. A review of all consecutive patients who received an intracorporeal left ventricular assist device at Duke University Medical Center from January 2004 to January 2011 was conducted. Cases of previous or concomitant aortic valve surgery were excluded. Data from the remaining implants (n = 184) and a control group of contemporaneous nonsurgical patients with end-stage heart failure (n = 132) were analyzed. Serial transthoracic echocardiography was used to characterize aortic valve regurgitation as a function of time. Left ventricular assist device implantation was associated with worsening aortic valve regurgitation, defined as an increase in aortic valve regurgitation grade, relative to the nonsurgical patients with end-stage heart failure (P < .0001). The recipients of continuous flow left ventricular assist devices were more likely than recipients of pulsatile left ventricular assist devices to develop worsening aortic valve regurgitation (P = .0348). Moderate or severe aortic valve regurgitation developed in 21 left ventricular assist device recipients; this was unrelated to the type of device implanted (continuous vs pulsatile; P = .754) or aortic valve regurgitation grade before left ventricular assist device implantation (P = .42). Five patients developed severe aortic valve regurgitation; all of whom underwent aortic valve procedures. Native aortic valve regurgitation developed and/or progressed after left ventricular assist device implantation, with this effect being more pronounced in continuous flow left ventricular assist device recipients. However, the preoperative aortic valve regurgitation grade failed to correlate with the development of substantial aortic valve regurgitation after left ventricular assist device implantation. After left ventricular assist device implantation, aortic valve regurgitation had a small, but discernible, clinical effect, with some patients developing severe aortic valve regurgitation and requiring aortic valve procedures. These data have implications for the long-term management of left ventricular assist device recipients, in particular as the durability of implantable continuous flow left ventricular assist device therapy improves.

Rajagopal K ，Daneshmand MA ，Patel CB ，Ganapathi AM ，Schechter MA ，Rogers JG ，Milano CA ... -  《-》

Durability of central aortic valve closure in patients with continuous flow left ventricular assist devices.

A competent aortic valve is essential to providing effective left ventricular assist device support. We have adopted a practice of central aortic valve closure by placing a simple coaptation stitch at left ventricular assist device implantation in patients with significant aortic insufficiency. We conducted a follow-up study to evaluate the efficacy and durability of this procedure. The study included patients who had undergone continuous flow left ventricular assist device implantation. The patients were divided into 2 groups, those who did not require any aortic procedure because the valve was competent and those who underwent central aortic valve closure for mild or greater aortic regurgitation. The clinical endpoints were mortality, progression or recurrence of aortic insufficiency, and reoperation for aortic valve pathologic features. Aortic insufficiency was measured qualitatively from mild to severe on a scale of 0 to 5. A total of 123 patients received continuous flow left ventricular assist devices from February 2007 to August 2011. Of those, 18 (15%) underwent central aortic valve closure at left ventricular assist device implantation because of significant aortic insufficiency (1.8 ± 1.4) and 105 who did not (competent aortic valve, 0.15 ± 0.43; P < .01). At follow-up (median, 312 days; range, 0-1429 days), the mean aortic insufficiency score remained low for the patients with central aortic valve closure (0.27 ± 0.46) in contrast to those without central aortic valve closure who experienced aortic insufficiency progression (0.78 ± 0.89; P = .02). In addition, the proportion of patients with more than mild aortic insufficiency was significantly less in the central aortic valve closure group (0% vs 18%; P = .05). The patients in the central aortic valve closure group were significantly older and had a greater incidence of renal failure at baseline. The 30-day mortality was greater in the central aortic valve closure group, but the late survival was similar between the 2 groups. No reoperations were required for recurrent aortic insufficiency. The results of our study have shown that repair of aortic insufficiency with a simple central coaptation stitch is effective and durable in left ventricular assist device-supported patients, with follow-up extending into 2 years. Although aortic insufficiency progressed over time in those with minimal native valve regurgitation initially, no such progression was noted in those with central aortic valve closure. Additional investigation is needed to evaluate whether prophylactic central aortic valve closure should be performed at left ventricular assist device implantation to avoid problematic aortic regurgitation developing over time, in particular in patients undergoing left ventricular assist device implantation for life-long (destination therapy) support.

McKellar SH ，Deo S ，Daly RC ，Durham LA 3rd ，Joyce LD ，Stulak JM ，Park SJ ... -  《-》

Surgical correction of aortic valve insufficiency after left ventricular assist device implantation.

New-onset aortic insufficiency (AI) can be encountered after instituting mechanical circulatory support and seems more common and severe with continuous flow (CF) left ventricular assist devices (LVADs) compared with pulsatile devices. Treatment algorithms for de novo, post-LVAD AI have not been well defined. In the present report, we have described 6 patients who underwent aortic valve surgery for new-onset post-LVAD AI. From 2005 to 2011, 271 patients underwent LVAD implantation. Of these LVADs, 225 were CF devices (203 HeartMate II devices, Thoratec Corp, Pleasanton, Calif; and 22 HVAD devices, HeartWare Intl, Inc, Framingham, Mass). The patients were examined for new-onset severe AI requiring surgical intervention. During follow-up, 6 CF LVAD patients developed new, severe AI that was accompanied by heart failure. After medical therapy had failed, 4 patients underwent redo sternotomy for aortic valve procedures (1 bioprosthetic valve replacement, 1 Dacron patch closure, and 2 aortic valve repairs), and 2 patients underwent transcatheter aortic valve procedure, with 1 requiring revision by open surgery for aortic valve replacement. Of the 6 patients, 5 experienced significant improvement in functional capacity and symptoms. One patient died postoperatively secondary to multiorgan failure and sepsis. Surgical treatment of post-LVAD AI with aortic valve oversewing or leaflet repair or by bioprosthetic aortic valve replacement is effective at restoring functional capacity for CF LVAD patients who develop symptomatic, severe AI and can be performed safely with good results. Various transcatheter approaches to these difficult problems are also available and offer less invasive alternatives to conventional surgery.

Atkins BZ ，Hashmi ZA ，Ganapathi AM ，Harrison JK ，Hughes GC ，Rogers JG ，Milano CA ... -  《-》

Durability and clinical impact of tricuspid valve procedures in patients receiving a continuous-flow left ventricular assist device.

Patients evaluated for a continuous-flow left ventricular assist device frequently present with severe right ventricular dysfunction with tricuspid regurgitation. Long-term outcomes of concurrent tricuspid valve procedures in continuous-flow left ventricular assist device implantation are unclear. From May 2004 to December 2013, 336 patients received continuous-flow left ventricular assist devices. Among these, 8 patients with prior tricuspid valve procedures were excluded. At continuous-flow left ventricular assist device implantation, 76 patients underwent tricuspid valve procedures (group A), including 68 repairs and 8 replacements. The remaining 252 patients did not receive concurrent tricuspid valve procedures (group B). Preoperatively, group A had higher central venous pressure/pulmonary capillary wedge pressure (P = .032), total bilirubin (P = .009), and percentage of moderate or greater tricuspid regurgitation (98.7% vs 18.8%; P < .001). In group A, cardiopulmonary bypass time (136 ± 52.0 minutes vs 83.9 ± 38.8 minutes; P < .001), intraoperative platelet use (13.6 ± 6.70 units vs 11.7 ± 5.92 units; P = .042), and bleeding requiring reoperation (27.5% vs 16.7%; P = .046) were significantly increased. In-hospital mortality was similar (10.5% vs 6.4%; P = .22). On-device 2-year survival was 73.9% in group A and 74.2% in group B (P = .24). At 2 years, mean cumulative readmissions for right heart failure was 0.21 in group A and 0.27 in group B (P = .95). A generalized linear mixed-effects model showed that tricuspid valve procedures are protective for developing future significant tricuspid regurgitation (odds ratio, 0.38; 95% confidence interval, 0.19-0.76; P = .006). Concomitant tricuspid valve procedures at continuous-flow left ventricular assist device implantation can be performed safely and are protective against worsening tricuspid regurgitation during the first 2 years of support.

Han J ，Takeda K ，Takayama H ，Kurlansky PA ，Mauro CM ，Colombo PC ，Yuzefpolskaya M ，Fukuhara S ，Truby LK ，Topkara VK ，Garan AR ，Mancini DM ，Naka Y ... -  《-》

Prevalence, significance, and management of aortic insufficiency in continuous flow left ventricular assist device recipients.

Jorde UP ，Uriel N ，Nahumi N ，Bejar D ，Gonzalez-Costello J ，Thomas SS ，Han J ，Morrison KA ，Jones S ，Kodali S ，Hahn RT ，Shames S ，Yuzefpolskaya M ，Colombo P ，Takayama H ，Naka Y ... -  《-》