Concomitant repair for mild aortic insufficiency and continuous-flow left ventricular assist devices

Abstract

Objectives: Aortic insufficiency (AI) after continuous-flow left ventricular assist device (CF-LVAD) implantation has become a highly relevant subject. However, management of pre-existing mild AI is unknown. We examined the fate of pre-existing mild AI during CF-LVAD support.

Methods: From March 2004 to October 2015, 446 consecutive patients received CF-LVAD. Of these, 56 (12.6%) patients with pre-existing mild AI were identified. Outcomes were compared between patients who underwent repair [n = 41 (73.2%); Group A] and those who did not [n = 15 (26.8%); Group B].

Results: Group A patients were more likely to have destination therapy intent at device insertion than Group B. Otherwise both groups displayed similar clinical/echocardiographic findings at baseline. There was no difference with respect to the occurrence of postoperative adverse events between groups. Kaplan-Meier analyses revealed the estimated 2-year on-device survival to be 63.3 ± 10.7 and 84.0 ± 10.6% (P = 0.41) and freedom from AI ≥moderate at 2 years to be 81.8 ± 9.7 and 45.0 ± 21.1% (P = 0.031) in Groups A and B, respectively. Furthermore, 83.3% (5 of 6) of Group B patients with large (>1.94 cm/m2; 75th percentile) body surface area-indexed aortic diameter developed ≥moderate AI, while none of the Group B individuals with smaller aortic root (0 of 9) did. In contrast, Group A patients with large indexed aortic root (n = 7) have all been free of AI at 2 years.

Conclusions: AI progression among CF-LVAD-supported patients with baseline mild AI is highly prevalent. Baseline aortic root diameter may help identify patients with 'borderline' AI lesion needing repair at device insertion.

Keywords: Aortic insufficiency; Aortic valve repair; Cardiac transplantation; Continuous-flow left ventricular assist device.