Treatment of aortic valve regurgitation (AR) is controversial if performed at the time of left ventricular (LV) assist device (LVAD) implantation. Aortic valve replacement (AVR) for chronic AR in the clinical setting of severe LV dysfunction carries a high mortality rate.1 Transcatheter AVR (TAVR) was used to treat native AR in the clinical circumstance of previous LVAD2,3 or concomitantly with LVAD implantation.4 We report the first case, to our knowledge, of concomitant valve-in-valve TAVR for severe prosthetic valve deterioration at the time of LVAD implantation.
A 69-year-old man with a long history of ischemic cardiomyopathy and severely reduced LV function presented with New York Heart Association class IIIB heart failure. He underwent AVR with a 25-mm valve (Mitroflow; Sorin Group, Saluggia, Italy) and coronary artery bypass grafting (left internal mammary artery to left anterior descending artery) 4 years ago for severe aortic valve stenosis. His medical history included previous myocardial infarction, percutaneous coronary intervention to the right coronary artery, hypertension, hyperlipidemia, chronic kidney disease (most recent creatinine, 2.5 mg/dL), persistent atrial fibrillation, implantation of cardiac resynchronization therapy device, and moderate chronic lung disease. Transthoracic echocardiography showed severe prosthetic aortic valve stenosis (mean pressure gradient, 42 mm Hg) with moderate central regurgitation. No paravalvular aortic regurgitation was found. Left ventricular ejection fraction was 11%, and LV end-diastolic diameter was 85 mm. Mitral valve regurgitation was severe and tricuspid valve regurgitation was moderate. Right ventricular systolic function was severely reduced (estimated systolic pressure, 48 mm Hg). Coronary angiography results showed patent bypass graft and patent right coronary artery. Chest computed tomography showed complete nonunion of the sternum. The patient's calculated Society of Thoracic Surgeons predicted risk of mortality was 8.92% for isolated AVR. Given the desire to eliminate an extensive cross-clamp period for redo-AVR, we elected to perform a valve-in-valve TAVR procedure at LVAD implantation.
We performed redosternotomy with extensive dissection of adhesions that surrounded the heart. We placed a purse-string suture on the distal ascending aorta and performed transaortic TAVR with a 26-mm valve (CoreValve; Medtronic, Inc, Minneapolis, MN USA) using fluoroscopy and transesophageal echocardiography. We performed an aortic root angiography and confirmed the height of coronary arteries. Deployment was successful and valve function was satisfactory. We then performed a cardiopulmonary bypass via arterial cannula on the ascending aorta and bicaval venous cannulation. We proceeded to core the LV apex, followed by a right atriotomy and tricuspid valve annuloplasty using a 28-mm annuloplasty ring (CarboMedics; LivaNova PLC, London, United Kingdom). Finally, we anastomosed the inflow cannula of the LV assist system (HeartMate II; Thoratec Corp, Pleasanton, CA USA) to the cardiac apex and the outflow cannula to the ascending aorta. Systemic cooling was not performed, and the heart was perfused and beating throughout the procedure.
The patient's chest was kept open and packed because of severe coagulopathy. On postoperative day 1, his chest was closed without hemodynamic impairment. Sternal plates were used because of the patient's previous nonunion. Postoperative chest radiograph showed good position of the transcatheter valve and LVAD (Fig. 1). The patient otherwise had a relatively uneventful postoperative course except for superficial sternal wound dehiscence. Postoperative transthoracic echocardiography did not show any aortic regurgitation. The mean pressure across the valve could not be obtained. The short-axis view for prosthetic aortic valve is shown in the Video, http://links.lww.com/INNOV/A117. The patient was discharged to a rehabilitation facility on postoperative day 16 with a New York Heart Association functional class II.
Management of AR at the LVAD implantation continues to be controversial. Surgical options include aortic valve closure, central coaptation stitch placement, repair, and replacement.5,6 However, these procedures require cardiopulmonary bypass and placement of an aortic cross-clamp. Aortic occlusion can cause further impairment of both right ventricular and LV functions after surgery when biventricular function is already severely reduced. The treatment for aortic valve disease with a severe LV dysfunction is controversial.7
John et al8 evaluated concomitant mitral, tricuspid, and aortic valve procedures performed at the time of LVAD implantation and found that only aortic valve procedures increased the mortality risk. They accounted for this outcome by the finding that aortic valve procedures represented the only concomitant procedure that requires cross-clamp of the aorta and were frequently associated with right ventricular failure.
In the present case, our patient had moderate prosthetic valve aortic regurgitation with advanced heart failure. Redo aortic valve surgery was considered; however, redo-AVR carries a greater risk than primary AVR.9 An excessive cross-clamp period likely would be required to perform a redo-AVR. Given the calcification of the tissue prosthesis, attempts at oversewing the valve likely would be unsuccessful. Our decision also was guided by concern that the patient's right ventricular function was marginal enough that he would have had a prolonged recovery from a redo-AVR, with increased risk of right ventricular assist device or death, or both.
In this case, no preoperative paravalvular AR was found. Therefore, we could achieve a good result without postoperative paravalvular AR. Because valve-in-valve procedure is used to reduce paravalvular AR after TAVR,10 a possibility exists that this hybrid approach can also be used to treat paravalvular AR at LVAD implantation.
Debate is considerable on the optimal strategy for AR treatment simultaneously with continuous-flow LVAD implantation. Structural valve deterioration is a concern (as with any prosthesis), and commissural fusion has been found at heart transplant in a patient who underwent bioprosthetic AVR simultaneously with LVAD surgery.11 The durability of the TAVR valve after implantation of continuous-flow LVAD has not been reported, and this clearly will be an area of interest because these patients continue to be monitored.
Both TAVR and LVAD implantation can carry procedural complications, and they are expensive technologies. Of importance is the careful selection of candidates. However, we believe that in cases such as this one, a hybrid approach has an important role. For these patients, surgical outcome and improved quality of life potentially justify the expense of the procedure. In conclusion, valve-in-valve TAVR can be a good alternative to standard open AVR for prosthetic valve deterioration at LVAD implantation.
1. Chaliki HP, Mohty D, Avierinos JF, et al. Outcomes after aortic valve replacement in patients with severe aortic regurgitation and markedly reduced left ventricular function. Circulation
2. Ganapathi AM, Hirji SA, Wang A, Patel CB, Gaca JG, Schroder JN. Bridge to long-term mechanical circulatory support with a left ventricular assist device: novel use of transcatheter aortic valve replacement. Ann Thorac Surg
3. D'Ancona G, Pasic M, Buz S, et al. TAVI for pure aortic valve insufficiency in a patient with a left ventricular assist device. Ann Thorac Surg
4. Baum C, Seiffert M, Treede H, Reichenspurner H, Deuse T. Concomitant transcatheter aortic valve and left ventricular assist device implantation. ASAIO J
5. Robertson JO, Naftel DC, Myers SL, et al. Concomitant aortic valve procedures in patients undergoing implantation of continuous-flow left ventricular assist devices: an INTERMACS database analysis. J Heart Lung Transplant
6. Lima B, Chamogeorgakis T, Mountis M, Gonzalez-Stawinski GV. Replacement of the aortic valve with a bioprosthesis at the time of continuous flow ventricular assist device implantation for preexisting aortic valve dysfunction. Proc (Bayl Univ Med Cent)
7. Onorati F, D'Errigo P, Grossi C, et al. Effect of severe left ventricular systolic dysfunction on hospital outcome after transcatheter aortic valve implantation or surgical aortic valve replacement: results from a propensity-matched population of the Italian OBSERVANT multicenter study. J Thorac Cardiovasc Surg
8. John R, Naka Y, Park SJ, et al. Impact of concurrent surgical valve procedures in patients receiving continuous-flow devices. J Thorac Cardiovasc Surg
9. Kaneko T, Vassileva CM, Englum B, et al. Contemporary outcomes of repeat aortic valve replacement: a benchmark for transcatheter valve-in-valve procedures. Ann Thorac Surg
10. Rodés-Cabau J, Dumont E, Doyle D. “Valve-in-valve” for the treatment of paravalvular leaks following transcatheter aortic valve implantation. Catheter Cardiovasc Interv
11. Doi A, Marasco SF, McGiffin DC. Is a bioprosthetic valve in the aortic position desirable with a continuous flow LVAD? J Card Surg