To the Editor:
As many as one third of patients with left ventricular assist devices (LVADs) will develop at least moderate aortic regurgitation within a few years.
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Aortic regurgitation decreases the efficiency of forward flow through the LVAD, leading to a decrease in oxygen supply, an increase in heart failure symptoms, recurrent hospitalizations, increased morbidity and mortality, and increased total healthcare costs. Patients with LVADs for destination therapy are often left with few options to stem the deleterious effects of aortic regurgitation. Off-label, transcatheter aortic valve replacement (TAVR) is increasingly being used as a treatment in LVAD patients with aortic regurgitation.5
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The procedure has been described in several case reports, but its anesthetic considerations have not been described. We performed a retrospective chart review and data analysis from March 2016 through October 2019 for all patients with LVAD who underwent a TAVR at our institution due to aortic regurgitation (Table 1).Table 1Patient Demographics and Outcomes Data.
| ID | Age | BSA | Sex | LVAD | LVAD Indication | Date of LVAD | Date of TAVR | Days from LVAD to TAVR | Preop Status | Outcomes | Comments |
|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 34 | 1.82 | F | HW | NICM: BTT | Sept 2015 | Mar 2016 | 181 | HF, AKI | OHT, PPD #159 | |
| 2 | 69 | 1.89 | M | HM2 | ICM: DT | Feb 2014 | May 2016 | 816 | HF, AKI | Death, PPD #927 | Hospice |
| 3 | 62 | 2.38 | M | HW | ICM & NICM: DT | May 2016 | Jun 2016 | 54 | Extremis, intubated, salvage procedure | Death, PPD #5 | Multiorgan failure |
| 4 | 65 | 2.03 | M | HW | NICM: BTT | Apr 2017 | June 2017 | 81 | HF, ARF | Death, PPD #102 | HF exacerbation, CKD |
| 5 | 70 | 2.05 | M | HW | IMC: DT | Jul 2016 | Dec 2017 | 519 | HF, DoE | Alive, #672 | |
| 6 | 72 | 1.68 | F | HM2 | NICM: DT | Oct 2014 | Apr 2018 | 1287 | HF, volume overload | Death, PPD #496 | Mechanical fall |
| 7 | 76 | 1.56 | F | HW | NICM: DT | Jun 2016 | Aug 2018 | 816 | HF, slow VT | Death, PPD #82 | |
| 8 | 31 | 2.17 | F | HM3 | NICM: DT | June 2018 | Sept 2019 | 463 | HF | Death, PPD #0 | TAVR valve migration |
Abbreviations: AKI, acute kidney injury; ARF, acute renal failure; BSA, body surface area; BTT, bridge-to-transplant; DT, destination therapy; CKD, chronic kidney disease; DoE, dyspnea on exertion; F, female; HF, heart failure; HM2, HeartMate II; HM3, HeartMate III; HW, HeartWare; ICM, ischemic cardiomyopathy; LVAD, left ventricular assist device; M, male; NICM, nonischemic cardiomyopathy; PPD, post-procedure day from TAVR; Preop, preoperative; TAVR, transcatheter aortic valve replacement; VT, ventricular tachycardia
Eight LVAD patients (6 destination therapy, 2 bridge to transplant were identified (age = 59 ± 17 years; time from LVAD to TAVR = 527 ± 429 days). Decompensated heart failure was the most common presentation with 6 subjects requiring admission for the symptoms prior to TAVR.
All LVAD patients underwent general anesthesia with transesophageal echocardiography monitoring. Three methods for annulus sizing were used: transesophageal echocardiography, computed tomography, and balloon annuloplasty were used in 3, 5, and 2 patients, respectively. Medtronic CoreValves (Medtronic, Santa Rosa, CA) were deployed using the transfemoral approach with rapid ventricular pacing at 120 to 125 beats per minute. Valve oversizing was 25% ± 11%. LVAD revolutions/minute were decreased by 23% ± 8% during deployment.
Two patients had moderate aortic regurgitation when their LVADs were originally placed. After TAVR, aortic regurgitation grades decreased from an average of moderate to trace in all but one patient, who had a large paravalvular leak and valve dehiscence. There was no significant change in right heart function before versus after TAVR. Five patients were extubated immediately after the procedure, and 5 were transferred to the cardiovascular intensive care unit. LVAD flow was directed by heart failure cardiology after surgery. One subject died intraoperatively during emergency surgery to repair the valve dehiscence. One patient was bridged-to-transplant on postTAVR day 159. One patient remained alive on post-TAVR day 672 with the original TAVR valve. Five patients died from nonprocedure related events within 322 days ± 388 days.
Patients with an LVAD with severe aortic regurgitation presenting for TAVR offer unique challenges. First, the flow from the LVAD outflow cannula causes an opposing, proximal force against the valve during deployment. This opposing LVAD force risks valve migration into the left ventricular outflow tract or left ventricle. This risk was mitigated by decreasing LVAD flows during deployment. Second, the patients lack the heavily calcified aortic annulus seen in those with aortic stenosis that is critical for anchoring the valve.
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This increases the risks of paravalvular leak, valve dehiscence or embolization, as seen in one patient here. 9
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Valve oversizing was used to provide adequate radial force to prevent valve migration and perivalvular leak. Unique concerns for evaluation of paravalvular regurgitation in the setting of an LVAD also required consideration. Due to prolonged or continuous aortic regurgitation flow associated with an LVAD, pressure half-time and pulsed Doppler evaluation of aortic diastolic flow were not useful. Further, more conservative grading scales were used to determine aortic regurgitation severity including vena contracta width ≥0.3 cm or a jet width/left ventricular outflow track width >46% at a Nyquist limit of 50 to 60 cm/s may be considered at least moderate if the aortic regurgitation jet is continuous.11
Conflict of Interest
None.
References
- Development of aortic insufficiency in patients supported with continuous flow left ventricular assist devices.ASAIO J. 2012; 58: 326-329
- The development of aortic insufficiency in left ventricular assist device-supported patients.Circ Heart Fail. 2010; 3: 668-674
- The development of aortic insufficiency in continuous-flow left ventricular assist device-supported patients.Ann Thorac Surg. 2013; 95: 493-498
- Aortic insufficiency during contemporary left ventricular assist device support: Analysis of the INTERMACS registry.JACC Heart Fail. 2018; 6: 951-960
- Management of aortic insufficiency using transcatheter aortic valve replacement in patients with left ventricular assist device support.ASAIO J. 2020; 66: e82-e86
- Transfemoral transcatheter aortic valve replacement with a self-expanding valve for severe aortic regurgitation in a patient with left ventricular assist device.J Card Surg. 2017; 32: 741-745
- Percutaneous transcatheter interventions for aortic insufficiency in continuous-flow left ventricular assist device patients: A systematic review and meta-analysis.ASAIO J. 2017; 63: 117-122
- Short-term results with transcatheter aortic valve replacement for treatment of left ventricular assist device patients with symptomatic aortic insufficiency.J Heart Lung Transplant. 2019; 38: 920-926
- Incidence, predictors, and outcomes of aortic regurgitation after transcatheter aortic valve replacement: Meta-analysis and systematic review Of Literature.J Am Coll Cardiol. 2013; 61: 1585-1595
- Paravalvular leak after transcatheter aortic valve replacement: The new achilles' heel? A comprehensive review of the literature.J Am Coll Cardiol. 2013; 61: 1125-1136
- Echocardiography in the management of patients with left ventricular assist devices: Recommendations from the american society of echocardiography.J Am Soc Echocardiogr. 2015; 28: 853-909
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Published online: March 23, 2022
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