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DOI: 10.1055/s-0032-1332339
Concomitant transcatheter aortic valve and left ventricular assist device implantation
Aims: Relevant aortic regurgitation (AR) requires surgical repair at the time of left ventricular assist device (LVAD) implantation to reduce recirculation. It is therefore our strategy to replace the aortic valve (AV) during LVAD implantation in all patients with more than mild AR. We here report on a patient, where concomitant transcatheter aortic valve implantation (TAVI) of a JenaValve prosthesis (JenaValve, Munich, Germany) and LVAD placement (HVAD, HeartWare, Framingham, MA) was performed in a single operation.
Case presentation: A 72-year-old male patient with ischemic cardiomyopathy and severely reduced left ventricular (LV) function presented with dyspnoea at rest (NYHA IIIb) and recurrent episodes of cardiac decompensation. His calculated logistic EuroSCORE was 38.94% (EuroSCORE II: 17.86%). Pre-operative echocardiography revealed moderate AR without any calcifications of the native valve or annulus. Because of extensive calcifications along the posterior wall of the ascending aorta, the patient was not suitable for surgical AV replacement. The patient was consented to undergo transapical TAVI and LVAD implantation. Via the usual transapical access, a 27 mm JenaValve prosthesis was implanted without prior balloon valvuloplasty or rapid ventricular pacing. Fluoroscopy and TEE confirmed adequate placement and optimal aortic bioprosthetic function. After redo sternotomy the apical purse-string sutures were removed, the HVAD sewing ring was attached and the HVAD pump secured. The outflow graft was anastomosed to the ascending aorta. After weaning from cardiopulmonary bypass, an adequate HVAD flow of 4.5 – 5 l/min was established. At 30-day follow-up, a mildly reduced right ventricular function was confirmed by echocardiography, no AR was seen. The patient was exercising with relieved dyspnoea (NYHA II).
Conclusion: In patients with LVAD-support, AR increases the recycling of regurgitant blood flow into the LV, reduces systemic flow and increases symptoms of heart failure. In patients with contraindications for cross-clamping, TAVI remains an option although anchoring of transcatheter heart valves is challenging in patients with pure AR. The concomitant JenaValve and LVAD implantation seems to be a promising hybrid procedure.