The Development of Aortic Insufficiency in Continuous-Flow Left Ventricular Assist Device–Supported Patients

doi:10.1016/j.athoracsur.2012.09.020

The Annals of Thoracic Surgery

Volume 95, Issue 2, February 2013, Pages 493-498

https://doi.org/10.1016/j.athoracsur.2012.09.020 Get rights and content

Background

Significant aortic insufficiency (AI) after left ventricular assist device (LVAD) placement affects device performance and end-organ perfusion. This study examined the development and progression of AI after implantation of continuous-flow LVAD.

Methods

Seventy-nine patients undergoing Heart Mate II (Thoratec Corp, Pleasanton, CA) LVAD implantation for predominantly destination therapy (n = 69 [87%]) were examined. Preoperative and postoperative echocardiograms for all patients were reviewed at the intervals of 0 to 3, 3 to 6, 6 to 12, 12 to 18, and 18 to 24 months. AI was graded on an interval scale of 0, none; 0.5, trivial; 1, mild; 1.5, mild to moderate; 2, moderate; 2.5, moderate to severe; and 3, severe. Development and progression of AI were analyzed.

Results

The incidence of significant AI (mild or greater) was 52% (n = 41). Median time to AI development was 187 days. The median duration of VAD support was 761 days. Mild AI developed in 41 patients (52%). No severe AI developed. In the Cox regression model (hazard ratio [95% confidence interval]), aortic valve closure (2.51 [1.06 to 5.89]; p = 0.03), and age (1.04 [1.008 to 1.08]; p = 0.01) were independent predictors of AI development. There was no difference in mortality rates in the two groups (p = 0.40 by log-rank test). A mixed-model linear regression analysis showed a significant overall progression of AI over time (β ± standard error, 0.06 ± 0.02; p = 0.006).

Conclusions

AI develops over time in a significant number of Heart Mate II LVAD patients. AI is more common in patients with closed aortic valves and in the older age group. As more patients require long-term VAD support, the development of AI will need careful attention and monitoring.

Section snippets

Material and Methods

This study was approved by the hospital Institutional Review Board and individual patient consent was waived.

Entire Patient Population

The analysis included 79 patients with HMII devices. Of these, 69 (87%) received the device for DT and 10 (13%) for BTT. The cohort was a mean age of 63.2 ± 11.8 years with a median duration of LVAD support of 761 days (range, 145 to 2434 days). Most patients were men (68 [85%]) and had ischemic cardiomyopathy (47 [59%]). The mean LV ejection fraction was 0.19 ± 0.08. Mild or greater AI developed in 41 of the 79 patients (52%) at a median of 187 days after LVAD implantation. Of these 41

Comment

Limitations in donor heart availability has led to the emergence in the use of LVADs in patients with end-stage heart failure as a permanent alternative to heart transplantation or DT. A potential complication that has increasingly been recognized recently has been the development of AI. In patients with preexisting AI, the severity of insufficiency often progresses [3, 4, 7, 8]. Significant AI can lead to ineffective LVAD output and end-organ malperfusion due to reduced forward flow (recycling

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Cited by (107)

Concurrent valvular procedures during left ventricular assist device implantation and outcomes: A comprehensive analysis of the Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy With HeartMate 3 trial portfolio
2023, Journal of Thoracic and Cardiovascular Surgery
Correction of valvular disease is often undertaken during left ventricular assist device (LVAD) implantation with uncertain benefit. We analyzed clinical outcomes with HeartMate 3 (HM3; Abbott) LVAD implantation in those with various concurrent valve procedures (HM3+VP) with those with an isolated LVAD implant (HM3 alone).
The study included 2200 patients with HM3 implanted within the Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy with HeartMate 3 (MOMENTUM 3) trial portfolio who underwent 820 concurrent procedures among which 466 (21.8%) were HM3+VP. VPs included 101 aortic, 61 mitral, 163 tricuspid; 85 patients had multiple VPs. Perioperative complications, major adverse events, and survival were analyzed.
Patients who underwent HM3+VP had higher-acuity Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profiles (1-2: 41% vs 31%) compared with no VPs (P < .05). The cardiopulmonary bypass time (124 vs 76 minutes; P < .0001) and hospital length of stay (20 vs 18 days; P < .0001) were longer in HM3+VP. A higher incidence of stroke (4.9% vs 2.4%), bleeding (33.9% vs 23.8%), and right heart failure (41.5% vs 29.6%) was noted in HM3+VP at 0 to 30 days (P < .01), with no difference in 30-day mortality (3.9% vs 3.3%) or 2-year survival (81.7% vs 80.8%). Analysis of individual VP showed no differences in survival compared to HM3 alone. No differences were noted among patients with either significant mitral (moderate or worse) or tricuspid (moderate or worse) regurgitation with or without corrective surgery.
Concurrent VPs, commonly performed during LVAD implantation, are associated with increased morbidity during the index hospitalization, with no effect on short- and long-term survival. There is sufficient equipoise to consider a randomized trial on the benefit of commonly performed VPs (such as mitral or tricuspid regurgitation correction), during LVAD implantation.
Transcatheter Aortic Valve Replacement in Patients With Left Ventricular Assist Devices and Aortic Regurgitation—Single Institution Retrospective Analysis
2022, Journal of Cardiothoracic and Vascular Anesthesia
Rate of thromboembolic and bleeding events in patients undergoing concomitant aortic valve surgery with left ventricular assist device implantation
2022, International Journal of Cardiology
Citation Excerpt :
During the last decade, the number of durable left ventricular assist device (LVAD) implantations has increased to unprecedented heights [1]. Valvular diseases including aortic regurgitation (AR) are associated with increased morbidity and mortality following LVAD implantation, due to a circulatory shortcut with the continuous flow [2,3]. Therefore, the International Society for Heart and Lung Transplantation [4] and the European Association for Cardio-Thoracic Surgery (EACTS) recommend that greater than mild AR, should prompt concomitant aortic valve replacement (AVR) or -repair during LVAD surgery [5,6].
Significant aortic regurgitation at the time of left ventricular assist device (LVAD) implantation, requires concomitant aortic valve (AoV) replacement or repair. However, the impact of concomitant AoV surgery on morbidity remains unknown. Therefore, our aim is to determine the impact of concomitant AoV surgery on thromboembolic and bleeding events.
A retrospective IMACS registry study, including patients implanted from 2013 until September 2017. Differences between different concomitant AoV surgery modalities were analyzed.
In total, 785 (5.1%) out of 15.267 patients (median age 58 IQR 49–66 years, 79% male) underwent concomitant AoV surgery (median age 63 IQR 54–69 years, 84% male); 386 (49%) patients received biological prostheses, 71 (9%) mechanical prostheses and 328 (42%) AoV repairs. In total, 54 (8%) patients with AoV surgery experienced a thromboembolic event and 1016 (9%) patients with no AoV surgery. Furthermore, concomitant AoV surgery was associated with an increased rate of all and nonsurgical bleedings. Following a multivariable Cox regression, concomitant AoV surgery remained an independent predictor for bleeding events.
In LVAD patients undergoing concomitant AoV surgery, thromboembolic event rates were not higher, however both all and nonsurgical bleeding event rates were higher.
Annuloplasty for Aortic Regurgitation in Univentricular Heart on Ventricular Assist Support
2021, Annals of Thoracic Surgery
Citation Excerpt :
Progressive AR is common after continuous flow VAD implantation. In adult patients, it has been demonstrated that at median follow-up of 5 years, 22% of patients had more than mild AR.1 Furthermore, progressive neoaortic root dilatation and neo-AR are recognized long-term complications after the Norwood procedure.2
Progressive aortic regurgitation is a common complication in patients supported with continuous flow ventricular assist devices. The risk of neoaortic regurgitation is likely to be particularly high in patients with univentricular hearts owing to the lack of fibrous support for the neoaortic valve. Previously described techniques for addressing neoaortic regurgitation in this setting have required cardiopulmonary bypass and cross clamping, or ligation of the neoaortic root. We present a simple technique of external partial annuloplasty of the neoaortic valve, which can be performed without the need for cardiopulmonary bypass or cross clamping.
The impact of uncorrected mild aortic insufficiency at the time of left ventricular assist device implantation
2020, Journal of Thoracic and Cardiovascular Surgery
The study objective was to investigate the progression of uncorrected mild aortic insufficiency and its impact on survival and functional status after left ventricular assist device implantation.
We retrospectively reviewed 694 consecutive patients who underwent implantation of a continuous-flow left ventricular assist device between January 2006 and March 2018. Pre–left ventricular assist device transthoracic echocardiography identified 111 patients with mild aortic insufficiency and 493 patients with trace or no aortic insufficiency. To adjust for differences in preoperative factors, propensity score matching was used, resulting in 101 matched patients in each of the mild aortic insufficiency and no aortic insufficiency groups.
Although both groups showed similar survival (P = .58), the mild aortic insufficiency group experienced higher incidence of readmission caused by heart failure (hazard ratio, 2.62; 95% confidence interval, 1.42-4.69; P < .01). By using the mixed effect model, pre–left ventricular assist device mild aortic insufficiency was a significant risk factor for both moderate or greater aortic insufficiency and worsening New York Heart Association functional status (P < .01).
Patients with uncorrected mild aortic insufficiency had a higher risk of progression to moderate or greater aortic insufficiency after left ventricular assist device implantation with worse functional status and higher incidence of readmission caused by heart failure compared with patients without aortic insufficiency. Further investigations into the safety and efficacy of concomitant aortic valve procedures for mild aortic insufficiency at the time of left ventricular assist device implant are warranted to improve patients' quality of life, considering the longer left ventricular assist device use as destination therapy and bridge to transplant with the new US heart allocation system.
Aortic Insufficiency After Left Ventricular Assist Device Implantation: Predictors and Outcomes
2020, Annals of Thoracic Surgery
The aim of this study was to evaluate the incidence, risk factors, and clinical impact of progression of aortic insufficiency (AI) after left ventricular assist device (LVAD) implantation.
Patients undergoing primary durable LVAD implantation between 2004 and 2018 were included. Significant AI was defined as more than mild AI. Clinical and echocardiographic data were collected. Patients were stratified by degree of pre-LVAD AI into 3 groups: no AI, group I; trace AI, group II; and mild AI, group III.
Three hundred sixteen eligible patients underwent LVAD implant, 229 patients (72.5%) in group I, 54 (17.1%) in group II, and 33 (10.4%) in group III. Median follow-up was 469 days. Forty-two patients (13.3%) progressed to significant AI during follow-up. Group III patients had the highest rate of developing significant AI (I, 10.0%; II, 13.0%; III, 36.4%; P = .002). Freedom from significant AI at 1 year after LVAD implant was 94.5% in group I, 86.1% in group II, and 62.4% in group III (P < .001). Predictors of developing significant AI included mild preoperative AI, ischemic cardiomyopathy, and shorter duration of LVAD support. Patients with significant AI after LVAD implantation had higher mortality compared with those without (59.5% vs 37.2%; P = .006).
Although some patients supported with an LVAD develop significant AI, this risk is increased in those with mild AI preoperatively. This finding, in conjunction with the increased mortality risk once significant AI develops, suggests that closer follow-up and management of LVAD patients with mild preoperative AI may be prudent.

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Original articleAdult cardiacThe Development of Aortic Insufficiency in Continuous-Flow Left Ventricular Assist Device–Supported Patients

Background

Methods

Results

Conclusions

Section snippets

Material and Methods

Entire Patient Population

Comment

J Heart Lung Transplant

Ann Thorac Surg

J Heart Lung Transplant

J Heart Lung Transplant

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Heart Lung Transplant

Original article
Adult cardiac
The Development of Aortic Insufficiency in Continuous-Flow Left Ventricular Assist Device–Supported Patients