Structural Heart Interventions in Patients with Left Ventricular Assist Devices

Abstract

Left ventricular assist devices (LVADs) have changed the landscape for patients with advanced heart failure (HF). With advances in pump design and management, patients with LVADs are living longer with improved quality of life despite having more comorbidities and complex structural heart disease. As such, HF cardiologists and surgeons collaborate more frequently with structural heart interventionalists to address the complex problems of patients with LVADs who present at different points of failure in their circuits. Unlike heart transplants and total artificial heart recipients, the native heart and its components must function to maintain successful circulatory support from these assist devices. Multiple points of potential failure of the native heart and the LVAD circuit exist that can result in significant morbidity and mortality. These include regurgitant valve lesions, interatrial shunts, outflow cannula obstruction, and pump thrombosis. Transcatheter interventions can be applied and tailored specifically to the anatomy of the individual in these situations to improve the lives and outcomes of our LVAD patients. This review provides a comprehensive approach for diagnosing and treating structural heart disease associated with patients who have LVADs, focusing on multidisciplinary collaboration and individualized interventional strategies.

Keywords: left ventricular assist device; transcatheter interventions; valvular heart disease.

Fig. 1.

Overview of structural heart interventions in LVAD patients. Multiple valve lesions can arise post LVAD that can be addressed with transcatheter valvular therapies. Aortic regurgitation can be treated with TAVR. Mitral and tricuspid regurgitation can be treated both by transcatheter edge to edge repair, as well as TMVR/TTVR strategies. PFO and iatrogenic ASD can complicate post LVAD management, typically by right to left shunting resulting in refractory hypoxemia. Post LVAD complications of pump thrombosis and outflow cannula obstruction can be treated in the catheterization laboratory. De-activation of the LVAD for patients with recovery require a hybrid procedure achieved in part by transcatheter delivery of closure devices inside the outflow cannula. LVAD, left ventricular assist devices; TAVR, transcatheter aortic valve replacement; TMVR, transcatheter mitral valve replacement; TTVR, transcatheter tricuspid valve replacement; PFO, patent foramen ovale; ASD, atrial septal defect.

Fig. 2.

Pathophysiology of aortic regurgitation post LVAD. In native circulation the transvalvular pressure (TVP) ranges from zero to peak systolic aortic pressure allowing a time of minimal stress on the aortic valve leaflets. In continuous flow circulation the TVP remains relatively constant thus creating an increased hemodynamic stress on valve leaflets contributing to the development of aortic regurgitation (AR) post LVAD.

Fig. 3.

Amplatzer closure of aortic valve. (a) Amplatzer septal occluder across native aortic valve. (b) TEE showing the two discs of the Amplatzer device closing the aortic valve. (c) Aortic regurgitation resolved after Amplatzer closure. TEE, transesophageal echocardiogram.

Fig. 4.

AVR with a self-expanding valve (Medtronic) in LVAD complicated by migration. (a) Medtronic Evolut valve deployed too deep in the ventricle. (b) Evolut valve embolized to the aorta when attempting to reposition the valve with a snare. (c) Second Evolut valve successfully placed across the aortic valve.

Fig. 5.

Jena-Valve in LVAD patient with severe AR. (a) Jenavalve 27 mm with three locators (arrowheads) anchored to the aortic valve. (b) Resolution of AR after Jenavalve implantation.

Fig. 6.

J Valve TAVR in LVAD patient with severe AR. (a) J-Valve with three anchor rings that secure in the aortic cusps. (b) J Valve implantation with resolution of AR (arrowhead pointing to anchor ring).

Fig. 7.

Abbott Navitor TAVR in LVAD patient. Abbott Navitor valve with large outflow diameter and anchoring in the ascending aorta for AR.

Fig. 8.

Tricuspid valve valve-in-ring TTVR in LVAD patient. (a) Sapien 3 valve being deployed in a TV annuloplasty band for treatment of severe TR via trans jugular approach. (b) T-TEER with Triclip. Torrential to mild TR after three Triclips. (Two previously placed Mitraclips are also visible on the fluoroscopy image). T-TEER, tricuspid transcatheter edge to edge repair; TV, tricuspid valve; TR, tricuspid regurgitation.

Fig. 9.

PFO closure post LVAD. (a) Large right to left shunt in a patient with PFO and RV failure. (b) Amplatzer closure of PFO in LVAD patient. (c) Successful closure of PFO with Gore 32 mm ASD occluder. Patient on RVAD support due to worsening RV failure in the settting of hypoxemia. RV, right ventricular; RVAD, right ventricular assist device.

Fig. 10.

Outflow cannula obstruction intervention. Outflow cannula obstruction treated with a large self-expanding vascular stent and dilated with a 10 mm balloon.

Fig. 11.

Catheter based thrombolytics in pump thrombosis. Pigtail catheter placed in the LV close to the LVAD inflow and thrombolytic infusion over a period of 24 hours. LV, left ventricle.

Fig. 12.

LVAD decommissioning. Outflow cannula occlusion with a series of three large Amplatzer vascular plug 2 (AVP2) from the proximal end to the distal end of the cannula.