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Transcatheter Aortic Valve Replacement in Patients With Left Ventricular Assist Devices and Aortic Regurgitation—Single Institution Retrospective Analysis

Published:March 23, 2022DOI:https://doi.org/10.1053/j.jvca.2022.03.020
      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.
      • Soleimani B
      • Haouzi A
      • Manoskey A
      • et al.
      Development of aortic insufficiency in patients supported with continuous flow left ventricular assist devices.
      • Cowger J
      • Pagani FD
      • Haft JW
      • et al.
      The development of aortic insufficiency in left ventricular assist device-supported patients.
      • Aggarwal A
      • Raghuvir R
      • Eryazici P
      • et al.
      The development of aortic insufficiency in continuous-flow left ventricular assist device-supported patients.
      • Truby LK
      • Garan AR
      • Givens RC
      • et al.
      Aortic insufficiency during contemporary left ventricular assist device support: Analysis of the INTERMACS registry.
      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.
      • Kar B
      • Prathipati P
      • Jumean M
      • et al.
      Management of aortic insufficiency using transcatheter aortic valve replacement in patients with left ventricular assist device support.
      • Rene AG
      • Desai N
      • Wald J
      • et al.
      Transfemoral transcatheter aortic valve replacement with a self-expanding valve for severe aortic regurgitation in a patient with left ventricular assist device.
      • Phan K
      • Haswell JM
      • Xu J
      • et al.
      Percutaneous transcatheter interventions for aortic insufficiency in continuous-flow left ventricular assist device patients: A systematic review and meta-analysis.
      • Yehya A
      • Rajagopal V
      • Meduri C
      • et al.
      Short-term results with transcatheter aortic valve replacement for treatment of left ventricular assist device patients with symptomatic aortic insufficiency.
      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.
      IDAgeBSASexLVADLVAD IndicationDate of LVADDate of TAVRDays from LVAD to TAVRPreop StatusOutcomesComments
      1341.82FHWNICM: BTTSept 2015Mar 2016181HF, AKIOHT, PPD #159
      2691.89MHM2ICM: DTFeb 2014May 2016816HF, AKIDeath, PPD #927Hospice
      3622.38MHWICM & NICM: DTMay 2016Jun 201654Extremis, intubated, salvage procedureDeath, PPD #5Multiorgan failure
      4652.03MHWNICM: BTTApr 2017June 201781HF, ARFDeath, PPD #102HF exacerbation, CKD
      5702.05MHWIMC: DTJul 2016Dec 2017519HF, DoEAlive, #672
      6721.68FHM2NICM: DTOct 2014Apr 20181287HF, volume overloadDeath, PPD #496Mechanical fall
      7761.56FHWNICM: DTJun 2016Aug 2018816HF, slow VTDeath, PPD #82
      8312.17FHM3NICM: DTJune 2018Sept 2019463HFDeath, PPD #0TAVR 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.
      • Yehya A
      • Rajagopal V
      • Meduri C
      • et al.
      Short-term results with transcatheter aortic valve replacement for treatment of left ventricular assist device patients with symptomatic aortic insufficiency.
      This increases the risks of paravalvular leak, valve dehiscence or embolization, as seen in one patient here.
      • Athappan G
      • Patvardhan E
      • Tuzcu EM
      • et al.
      Incidence, predictors, and outcomes of aortic regurgitation after transcatheter aortic valve replacement: Meta-analysis and systematic review Of Literature.
      ,
      • Généreux P
      • Head SJ
      • Hahn R
      • et al.
      Paravalvular leak after transcatheter aortic valve replacement: The new achilles' heel? A comprehensive review of the literature.
      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.
      • Stainback RF
      • Estep JD
      • Agler DA
      • et al.
      Echocardiography in the management of patients with left ventricular assist devices: Recommendations from the american society of echocardiography.

      Conflict of Interest

      None.

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