During left ventricular assist device (LVAD) implantation, concomitant aortic valve (AV) replacement, repair, or occlusion is mandatory in patients with moderate to severe AV insufficiency.1 Thus, recirculation can be avoided and appropriate forward flow can be ensured.2 Post-LVAD right ventricular failure (RVF) is a formidable complication, and the patient population with concomitant AV surgery is at increased risk.2,3 That is because traditionally, these operations have been performed via median sternotomy, with longitudinal opening of the pericardium, and using cardioplegic arrest. These features increase the risk for RVF and should be avoided. We herein report on a patient with severe left ventricular (LV) failure from ischemic cardiomyopathy and moderate AV insufficiency, who underwent concomitant minimally invasive LVAD implantation and transapical transcatheter aortic valve replacement (TAVR).
A 76 year-old male patient was transferred to our institution for coronary artery bypass surgery. The patient experienced long-standing ischemic cardiomyopathy with severely reduced LV function, dyspnea (New York Heart Association III), and angina pectoris (Canadian Cardiovascular Society III). Coronary angiography revealed high-grade stenoses of the left main trunk (LMT), the proximal left anterior descending artery (LAD), and the right coronary artery. Transesophageal echocardiography (TEE) showed a left ventricular ejection fraction of 30%, a left ventricular end-diastolic diameter of 70.5 mm, and a moderately reduced right ventricular (RV) function with tricuspid annular plane systolic excursion of 10 mm and right ventricular systolic pressure (RVSP) of 79 mm Hg. The AV was moderately (Figure 1A) and the mitral valve severely insufficient. Further diagnoses included rheumatoid arthritis and a history of stomach resection for therapy-resistant ulcer and bleeding. Because of the increased risk profile, culminating in logistic (log) EuroSCORE I and II of 40.32% and 35.84% and Society of Thoracic Surgeons M&M Score of 83.9%, and the unlikely success of cardiac bypass surgery, a decision for LVAD implantation as destination therapy was made. To avoid recirculation under HeartWare ventricular assist device (HVAD) therapy, concomitant aortic valve replacement (AVR) was scheduled. Because of the elevated risk for RVF from an RV with preexisting RV dysfunction, the decision for concomitant TAVR was made. The annulus was measured via 3mensio software (3mensio Medical Imaging BV, AK Bilthoven, NL) with a result of 27.5 mm and a transapical LV apex access via fifth to sixth intercostal space (ICS) seemed appropriate (Figure 1, B and C). Before surgery, percutaneous transluminal coronary angioplasty (PTCA) with consecutive stent implantation of the LMT and LAD was performed to relieve angina.
The described procedure was performed in a hybrid operating room by an interdisciplinary team consisting of cardiac surgeons and cardiologists. The patient was placed in supine position, prepared, and draped. Cardiopulmonary bypass (CPB) was established via limited groin incision and cannulation of the femoral artery and vein. Next, a left-sided 8 cm anterior thoracotomy was performed in the fifth ICS to access the LV apex. After placement of the soft tissue retractor, insertion of an intercostal retractor, and limited opening of the pericardium, the HVAD sewing ring was placed under normothermic CPB support (Figure 2A). Simultaneously, a 5 cm anterior parasternal skin incision was performed and the second right ICS was entered.
Subsequently, a transapical guidewire was inserted in the middle of the sewing ring, and the crimped 27 mm JenaValve (JenaValve Technology, GmbH, Munich, Germany) transcatheter heart valve (THV) was introduced (Figure 2B) and deployed into the AV annulus without prior balloon valvuloplasty (Figure 2, C and D) (see Video, Supplemental Digital Content 1, http://links.lww.com/ASAIO/A55). These steps were performed on the beating heart without the use of rapid ventricular pacing (RVP). The JenaValve THV was used because of CE mark approval for aortic insufficiency. After balloon postdilation (Figure 2E) (see Video, Supplemental Digital Content 2, http://links.lww.com/ASAIO/A56), fluoroscopy and echocardiography confirmed an adequate position and function of the THV without transvalvular (TVL) and trace paravalvular leakage (PVL) (Figure 2F).
Because of absent purse-string sutures, the apex was “finger-occluded” (Figure 3A), cored, and the HVAD pump was inserted (Figure 3B). The driveline was tunneled to exit in the lower abdomen, and the outflow graft was intrapericardially pulled toward the parasternal thoracotomy. After careful placement of a side-biting clamp, the graft-to-aorta anastomosis was performed (Figure 3C).
After de-airing and setting the appropriate pump speed, the RV presented a satisfying function in TEE. Nitric oxide was started, and the patient was weaned from CPB with mild to moderate catecholamine support. An adequate HVAD flow of 4 L/min was established and the patient transferred to the intensive care unit.
The patient was extubated the next day and discharged after 14 days. TTE before discharge presented a permanently closed THV without any TVL and only trace PVL. The pump speed was 2300 RPM and the average flow 3 L/min. At 30 day follow-up, there were no major or minor complications.
Right ventricular failure after LVAD implantation reduces survival and increases perioperative mortality.4 It has been reported that LVAD implantation with concomitant surgical valve procedures, especially of the AV, leads to increased post-LAVD RVF.3 It is assumed that this circumstance is a consequence of cardioplegic arrest during surgical AVR and altered pericardial geometry with consecutive RV dilation.3,5 To avoid surgical valve replacement, the TAVR procedure is an appropriate alternative.2 We herein reported the first case of a transapical TAVR with concomitant minimally invasive HVAD implantation through left anterior and right anterior thoracotomies. We believe that this hybrid procedure with avoidance of surgical AVR, longitudinal opening of the pericardium, and cardioplegia is an ideal approach for these patients. In the presented case, we could prevent RVF and did not encounter complications.
The choice of the THV depends on the pathophysiology of the native AV. In most cases, AV insufficiency is the reason for scheduled AVR during LVAD implantation. The JenaValve was chosen because it does not need calcifications, can be implanted without the use of RVP, and is instantly fully functional. After studying the prosthesis for this indication, we recommend this valve for concomitant AV implantation for pure aortic regurgitation.6 The transapical approach through the left thoracotomy and insertion of the delivery system through the LVAD sewing ring is a comfortable solution and leads to a short operation time. It has to be considered that there are strategies needed for possible malfunction of the THV. If moderate or severe TVL or PVL occurs, valve-in-valve procedures should be taken into consideration. Because the transapical approach would be blocked by the HVAD pump, this procedure would have to be performed through a transfemoral access. Therefore, a computed tomography angiography for aortoiliofemoral evaluation is advisable before surgery.
Thrombosis of native and prosthetic AV is a described complication after LVAD implantation.7 A low flow across bioprosthetic valves can lead to an increased risk of thromboembolism. Transcatheter heart valve has a stent geometry not comparable with traditional biological or mechanical heart valve prostheses. They are made of Nitinol (JenaValve) or cobalt chromium and are produced with a stent profile, extending into the ascending aorta. Because of the little experience with THV and LVAD, those patients have to be monitored in short-term intervals to detect potential thromboembolic complications of the THV timely.
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4. McMurray JJ, Adamopoulos S, Anker SD, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2012;33:1787–1847
5. Deuse T, Reichenspurner H. Do not touch the sternum—Thoracotomy incisions for HVAD implantation. ASAIO J. 2014;60:234–236
6. Seiffert M, Diemert P, Koschyk D, et al. Transapical implantation of a second-generation transcatheter heart valve in patients with noncalcified aortic regurgitation. JACC Cardiovasc Interv. 2013;6:590–597
7. Mokashi SA, Schmitto JD, Lee LS, et al. Ventricular assist device in patients with prosthetic heart valves. Artif Organs. 2010;34:1030–1034
mechanical circulatory support; LVAD; minimally invasive; TAVR; transapical