Transcatheter Aortic Valve Replacement in a LVAD Patient with an Aortic Regurgitation Re- Entry Flow Circuit
Arthur Davis MD, Justin Price MD, Austin Tutor MD, Stephen Ramee MD, Jose Tafur Soto MD
Introduction: Left ventricular assist devices (LVAD) are frequently used therapy for patients with advanced heart failure (HF) as a bridge to transplant and as destination therapy. LVADs operate under ‘continuous flow’ which requires off -loading of the left ventricle (LV) by a fistulous tract created via cannulation of the apex of the LV. Blood from the LV flows through a conduit and into the ascending aorta, which is cannulated at device implantation. Valvular disease, in particular aortic valve (AV) pathology, is investigated prior to LVAD implantation as aortic regurgitation (AR) can form a circuit from the outflow cannula back into the LV. If significant AR exists, the AV is surgically repaired at the time of LVAD implantation. Transcatheter aortic valve replacement (TAVR) has been shown to improve outcomes in patients with aortic stenosis but is not currently approved for AR. Case Presentation: A 66 year old male with a LVAD implanted as destination therapy for ischemic cardiomyopathy presented with NYHA class IV heart failure symptoms. On transthoracic echocardiogram, moderate, continuous aortic regurgitation was noted with a dilated left ventricle (LVIDd 9.43cm, LVIDs 9.12cm.) A 20mm Edwards Sapien S3 was successfully implanted with immediate symptomatic relief to NYHA class 1. He was discharged home with outpatient echocardiogram pending. Discussion: In LVAD patients, AR can worsen hemodynamics leading to decompensated HF. Previous studies have demonstrated 25-40% of LVAD patients will develop AR within 1 year. The mechanism is postulated to be secondary to minimal AV opening with resultant leaflet fibrosis and leaflet tip retraction. In patients with known AR prior to LVAD placement, sewing of the valve (Park stitch) or surgical replacement is commonly performed depending on the etiology of the AR. However, there is no consensus opinion nor guidelines on treatment options for AR that complicates existing LVAD therapy. Conclusion: AR in LVAD patients creates a circuit of blood flow from the outflow cannula retrograde into the LV, which can lead to ineffective LV unloading and worsening NYHA classification. We demonstrated the successful implantation of a TAVR valve with immediate symptoms improvement. TAVR implantation may be a viable treatment option for non-surgical candidate LVAD patients with AR.
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