Short-term results with transcatheter aortic valve replacement for treatment of left ventricular assist device patients with symptomatic aortic insufficiency

doi:10.1016/j.healun.2019.03.001

The Journal of Heart and Lung Transplantation

Volume 38, Issue 9, September 2019, Pages 920-926

https://doi.org/10.1016/j.healun.2019.03.001 Get rights and content

BACKGROUND

After 3 years of continuous-flow left ventricular assist device (CF-LVAD) support, nearly a third of patients develop at least moderate aortic insufficiency (AI). Percutaneous occluder devices, surgical aortic valve replacement (SAVR), and urgent heart transplantation are available treatment options. Transcatheter aortic valve replacement (TAVR) has not been widely used for treating symptomatic AI in patients on LVAD support.

METHODS

Retrospective chart review and data analysis from October 2010 through August 2017 was performed. A total of 286 patients with end-stage heart failure (ESHF) were implanted with a durable CF-LVAD. Nine patients subsequently developed significant symptomatic AI, which was treated with TAVR.

RESULTS

All 9 patients had 1 TAVR procedure with resolution of AI and were discharged home. Procedural complications include valve migration warranting a second valve for stabilization, retroperitoneal and groin hematoma, and pseudoaneurysm requiring thrombin injection. A significant improvement of the New York Heart Association classification was noted from the time of implant to 6 months. Two patients had unplanned heart failure‒related hospitalizations within 6 months. At 6 months, 89% of patients were alive on LVAD support.

CONCLUSIONS

TAVR is a successful treatment modality for LVAD patients who develop symptomatic AI.

Section snippets

Methods

Between October 2010 and August 2017, 286 patients underwent LVAD implantation with a HeartMate II continuous-flow axial pump (Abbott) at the Piedmont Heart Institute (PHI). Nine patients on LVAD support developed symptomatic AI and were treated with TAVR by either CoreValve or Evolut R (Medtronic) and had 6-month follow-up. As of January 1, 2019, the median follow-up period post-TAVR was 513 (range 155–923) days. All 9 patients were evaluated by a multidisciplinary team of cardiothoracic

Patients’ characteristics

A total of 286 patients had HeartMate II implantation at our facility, 4 of these patients had concomitant AV interventions for moderate to severe AI at the time of LVAD surgery. We assessed 9 patients with a median age at the time of TAVR of 51 (range 42‒74) years; 78% of the patients were male, and 55% were black and 45% were white (Table 1). Two of the 9 patients had concomitant AV interventions at the time of LVAD implant with Park stitch. The remaining patients had no significant AI at the

Discussion

Up to 30% of patients develop at least moderate AI after 3 years or longer on CF-LVAD support.4, 6, 7 The etiology of AI is believed to be associated with lack of AV opening, increased sheer stress, abnormal collagen production and remodeling, and increased diastolic pressures with continuous LV unloading.8, 9

With AI, regurgitant blood circles back to the LV through a low-resistance circuit reducing the LVAD efficacy, leading to compromised cardiac output, end-organ hypoperfusion, and HF. There

Disclosure statement

A.Y. served as a consultant for St. Jude Medical for fellows-in-training education program in 2016. A.K. has received speaker honoraria from Novartis. C.M. has received speaker honoraria from Boston Scientific and Medtronic. The remaining authors have no conflicts of interest to disclose.

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We report a rare approach employed for management of aortic insufficiency (AI) in a patient who also had an aortic root thrombus and left ventricular assist device (LVAD) that traditionally requires cardiac transplantation. Our patient had a favorable outcome with a minimally invasive transcatheter aortic valve replacement. With this case, we hope to generate awareness amongst physicians treating patients about management alternatives and approach of a commonly encountered, life-threatening complication of AI in patients with LVAD.
Late Right Heart Failure After Left Ventricular Assist Device Implantation: Contemporary Insights and Future Perspectives
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Late right heart failure (RHF) is increasingly recognized in patients with long-term left ventricular assist device (LVAD) support and is associated with decreased survival and increased incidence of adverse events such as gastrointestinal bleeding and stroke. Progression of right ventricular (RV) dysfunction to clinical syndrome of late RHF in patients supported with LVAD is dependent on the severity of pre-existing RV dysfunction, persistent or worsening left- or right-sided valvular heart disease, pulmonary hypertension, inadequate or excessive left ventricular unloading, and/or progression of the underlying cardiac disease. RHF likely represents a continuum of risk with early presentation and progression to late RHF. However, de novo RHF develops in a subset of patients leading to increased diuretic requirement, arrhythmias, renal and hepatic dysfunction, and heart failure hospitalizations. The distinction between isolated late RHF and RHF due to left-sided contributions is lacking in registry studies and should be the focus of future registry data collection. Potential management strategies include optimization of RV preload and afterload, neurohormonal blockade, LVAD speed optimization, and treatment of concomitant valvular disease. In this review, the authors discuss definition, pathophysiology, prevention, and management of late RHF.
Transcatheter Aortic Valve Replacement for Left Ventricular Assist Device–Related Aortic Regurgitation: The Michigan Medicine Experience
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Aortic regurgitation (AR) is common and detrimental in patients with left ventricular assist devices (LVADs). Off-label use of transcatheter aortic valve replacement (TAVR) has emerged as a potential treatment option. Further data are required regarding the feasibility and outcomes of TAVR to treat AR in LVAD recipients.
A retrospective review of all patients with LVADs who underwent TAVR for the treatment of AR at a single center was performed. All echocardiograms were independently reviewed to ensure accuracy.
Eleven patients with continuous-flow LVADs underwent TAVR for AR. All patients had moderate or severe AR with New York Heart Association (NYHA) class III and IV symptoms. Implantation of more than 1 valve was required in 4 (36.3%) patients; 1 patient died during the procedure because of valve migration into the left ventricle and 1 patient died in-hospital after TAVR. Of 9 (81.8%) patients discharged alive, 8 (72.7%) were alive at 12 months and all survivors had improvement in AR severity, natriuretic peptide levels, left ventricle end-diastolic diameter, and NYHA class. Five (62.5%) survivors had a large improvement (>20 points) in the Kansas City Cardiomyopathy Questionnaire score at 1 year. One survivor experienced heart failure, requiring hospitalization, within 1 year.
In this single-center series, TAVR for the treatment of AR in patients with LVADs is technically challenging but feasible in select patients and may produce durable improvements in AR severity, functional status, and quality of life.
Clinical Outcomes of Transcatheter Aortic Valve Replacement (TAVR) Vs. Surgical Aortic Valve Replacement (SAVR) in Patients With Durable Left Ventricular Assist Device (LVAD)
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Citation Excerpt :
The presence of LVAD further increases the risk of valve migration into the LV due to the suction effect of the inflow cannula. Despite these challenges, there have seen small series of published cases with successful TAVR implantation in LVAD patients with one series showing 89% 6-month survival and small series showing good 3-year outcomes.8,9 The various proposed approaches to increase the procedural success include oversizing the valve relative to the aortic annulus with one study suggesting 15% oversizing, reducing the LVAD speed during implantation, and using the newer generation valves that have better anchoring mechanism.10,11.
Patients with left ventricular assist device (LVAD) often develop aortic insufficiency requiring an intervention on the aortic valve. We sought to analyze the outcomes of patients with a history of LVAD who underwent either transcatheter aortic valve replacement or surgical aortic valve replacement. The Nationwide Readmission Database was used to extract relevant patient information from January 1, 2016, to December 31, 2018. The Nationwide Readmission Database is a nationally representative sample of all-payer discharges from United States nonfederal hospitals. The primary outcome of interest was in-hospital mortality. Secondary outcomes included length of stay, clinical outcomes, costs, and 30-day all-cause readmissions. Complex samples multivariable logistic and linear regression models were used to determine the association of procedure type with outcomes. Among 148 hospitalizations with a history of LVAD, 87 underwent transcatheter aortic valve replacement (TAVR), and 61 underwent surgical aortic valve replacement (SAVR). The inpatient mortality in SAVR group was numerically higher compared to the TAVR cohort, however, it did not reach statistical significance. The use of invasive mechanical ventilation, and rates of cardiogenic shock, bleeding, and vascular complications were higher in the SAVR cohort compared to the TAVR cohort. The mean length of stay and costs were higher in the SAVR cohort compared to the TAVR cohort. The 30-day all-cause readmission rate was numerically higher in the SAVR group but not statistically significant. TAVR in patients with LVAD may be a viable treatment option for patients with AI with potential for better inpatient mortality and inpatient outcomes compared to patients who undergo SAVR in appropriately selected patients.
Transcatheter Aortic Valve Replacement in Patients With Left Ventricular Assist Devices and Aortic Regurgitation—Single Institution Retrospective Analysis
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Short-term results with transcatheter aortic valve replacement for treatment of left ventricular assist device patients with symptomatic aortic insufficiency

BACKGROUND

METHODS

RESULTS

CONCLUSIONS

Section snippets

Methods

Patients’ characteristics

Discussion

Disclosure statement

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