Partial aortic valve fusion induced by left ventricular assist device

doi:10.1016/S0003-4975(00)01929-9

The Annals of Thoracic Surgery

Volume 70, Issue 4, October 2000, Pages 1270-1274

https://doi.org/10.1016/S0003-4975(00)01929-9 Get rights and content

Abstract

Background. Left ventricular assist devices (LVADs) may be used (1) as a bridging device to cardiac transplantation, (2) for permanent replacement of left ventricular function, and (3) as a bridge to recovery of ventricular function, for example, in recoverable myocardial disease. In this third group of patients, it is important that the LVAD does not produce changes in the heart that will have a deleterious effect on cardiac function once the device is removed. Furthermore, if the LVAD fails, survival depends on optimal function of the diseased heart.

Methods. All hearts with LVADs encountered as surgical specimens following heart transplantation or at autopsy at the Fairview-University of Minnesota Medical Center during the 5-month period August 1998 to January 1999 were examined for native valvular heart disease. The nature and extent of commissural fusion was noted and measured. Light microscopy was performed on any valve lesions.

Results. Four of 6 patients with HeartMate (Thermo Cardiosystems, Inc, Woburn, MA) LVADs showed evidence of commissural fusion (acquired aortic stenosis). In 1 patient, this condition was caused by an organizing thrombus uniting a 14-mm length of the commissural region of the right coronary and noncoronary cusps of the aortic valve. Fibrous commissural fusion due to totally organized thrombus in the other 3 patients affected one aortic commissure (2 patients, 2 mm and 4 mm, respectively) and two commissures (1 patient, 2 mm and 5 mm). Partial cuspal fusion in each case was due to permanent closure of the native aortic valve induced by the LVAD’s operating in its automatic setting. Mean length of commissural fusion was 5.4 mm (range, 2 to 14 mm; standard deviation [SD] = ±5.0 mm). Mean duration of implantation of the six LVADs was 180.3 days (range, 26 to 689 days; SD = ±253.8 days). The LVADs of the 3 patients with fibrous fusion of the commissures had been implanted for an average of 252.3 days (range, 26 to 689 days; SD = ±378.2 days).

Conclusions. Normal function of the LVAD produces permanent closure of the native aortic valve. Stasis on the ventricular aspect of the aortic valve, combined with a low level of anticoagulation, favors thrombosis at this site. Thrombus organization leads to aortic stenosis of variable severity. This previously unsuspected complication was not detected clinically in any of our patients. Aortic stenosis may hold serious implications for patients in whom the LVAD acts as a bridge to recovery or in those in whom the LVAD fails. Prevention may be achieved by intermittently reducing LVAD pumping action. A built-in venting cycle would be of value in long-term implants. Thrombi on the aortic valve may also predispose patients to infective endocarditis, because bloodstream infection is common in patients with LVADs.

Section snippets

Material and methods

During the period January 1995 to January 1999, 26 HeartMate LVADs have been implanted at the Fairview-University Medical Center. All patients with implants received one aspirin daily for anticoagulation, and the LVAD pump was vented once per nursing shift. Left ventricular function stayed depressed in most patients on echo assessment. The native aortic valve stayed closed during the automatic pumping mode. All hearts bearing a HeartMate LVAD, including hearts explanted at cardiac

Results

We encountered six hearts with an implanted HeartMate LVAD; three were explanted recipient hearts following cardiac transplantation, and three were autopsy hearts. Five out of the six HeartMate LVADs (those in hearts 1, 2, 3, 4, and 6) were pneumatically powered (model 1000 IP devices), and one heart (heart 5) had the HeartMate VE (vented electrical) model. Clinicopathologic data are given in Table 1and Fig 1, Fig 2, Fig 3.

Morphologic evidence of acquired aortic valvular disease (Table 1) was

Comment

A recent comprehensive review of implantable LVADs [11] lists only the following as possible complications of LVADs: (1) the most common early complications are bleeding, right-sided heart failure, air embolism, and progressive multisystem organ failure; and (2) the most common late complications are infection, thromboembolism, and device failure. Although the review discusses hemodynamic features of the blood flow in LVAD recipients with various valvular lesions, no mention is made of any

Addendum

Subsequent to the submission of this manuscript, we have encountered 3 additional patients with partial aortic valve commissural fusion associated with the presence of a LVAD. The heart of 1 of these patients, who had a LVAD for 165 days, is illustrated in Figure 4.

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Original article: cardiovascularPartial aortic valve fusion induced by left ventricular assist device

Abstract

Section snippets

Material and methods

Results

Comment

Addendum

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

J Am Coll Cardiol

Ann Thorac Surg

Clinical use of the total artificial heart

N Engl J Med

Original article: cardiovascular
Partial aortic valve fusion induced by left ventricular assist device