Concomitant Repair For Mild Aortic
Insufficiency And Implantation Of Left Ventricle Mechanical Support
Authors:
Arun K. Singhal, MD, PhD, FACS
Clinical Associate Professor, Department of Cardiothoracic Surgery
University of Iowa Hospitals & Clinics
arun-singhal@uiowa.edu
Jarrod Bang, MD
Department of Anesthesia, University of Iowa Carver College of Medicine
jarrod-bang@uiowa.edu
Anthony L. Panos, MD, MSc, FRCSC, FACS
Professor, Department of Cardiothoracic Surgery
Director of Heart Transplant and Mechanical Cardiac Support Programs
University of Iowa Hospitals & Clinics
anthony-panos@uiowa.edu
Andrew Feider, MD
Associate Professor
Division Director, Cardiothoracic Anesthesia
Department of Anesthesia
University of Iowa Carver College of Medicine
andrew-feider@uiowa.edu
Satoshi Hanada, MD
Clinical Associate Professor of Anesthesia
Department of Anesthesia, University of Iowa Carver College of Medicine
satoshi-hanada@uiowa.edu
J. Scott Rankin, MD
Professor, Department of Cardiovascular and Thoracic Surgery
WVU Heart and Vascular Institute
West Virginia University
jsrankinmd@cs.com
Corresponding Author:
Arun K. Singhal, MD, PhD, FACS
Clinical Associate Professor, Department of Cardiothoracic Surgery
University of Iowa Hospitals & Clinics
arun-singhal@uiowa.edu
Running Title: Repair Aortic Insufficiency For Left Ventricle Assist
Device
Abbreviations:
AI: Aortic Value Insufficiency
AV: Aortic Valve
DT: Destination Therapy
EF: Ejection Fraction
LVAD: Left Ventricular Assist Devices
TEE: Transesophageal Echo
Key Words
LVAD, aortic valve regurgitation, aortic valve repair, HAART Ring,
complications, heart failure, non-ischemic cardiomyopathy
Abstract
Aortic valve regurgitation in patients undergoing LVAD implantation is a
significant complication which occurs in up to 10% of patients in the
INTERMACS database. Patients who have aortic valve regurgitation at the
time of implant have been handled by several methods, including aortic
valve leaflets approximation, to aortic valve replacement or even valve
closure.
We report a case where we used HAART Ring to repair a regurgitant aortic
valve during LAVD implant for destination therapy.
Introduction
Aortic value insufficiency (AI) is a significant complication of left
ventricular assist devices (LVAD). In a recent INTERMACS registry
analysis,10.7% of patients developed moderate to severe AI in a time
dependent fashion and was associated with decreased survival.(1) Since
AI is generally considered unfavorable in this population, multiple
mitigation strategies have been developed. The first is prediction of
patients who may develop AI which include smaller body surface area,
older age, female sex, and dilated aortic roots.(2) The second is
aggressive valve treatment strategies which fall into either
intervention at time of surgery versus treatment post occurrence.
Treatment strategies fall into two categories: valve replacement,
central oversewing or even valve closure in selected cases.(3)
Additionally, Impella placement may be a separate risk factor for AI in
durable LVADs.(4) Central oversewing is safe and effective but in case
of LVAD stoppage risks sudden death and may complicate assessment of
left ventricular function. Replacement with bioprosthetic AVR has risks
associated with value thrombosis. At present neither strategy is
optimal.
Case Report
We report the use of a HAART 300 ring and associated leaflet repair
during LVAD implantation in 56-year-old Caucasian female with acute
exacerbation of her chronic congestive heart failure (CHF). Her history
is significant for biventricular reduced ejection fraction (EF)
secondary to prior chemotherapy, single vessel left anterior descending
artery with previous stent, left bundle branch block, Type 2 diabetes
mellitus and hyperlipidemia. Left ventricular ejection faction was 1155.
She was admitted, started on inotropes, and had therapy escalated to an
Impella 5.5. She developed high panel reactive antigens and was offered
a Heartmate 3 LVAD as DT. Preoperative transesophageal echo (TEE)
revealed an Impella device across the aortic valve (AV) between the
non-coronary and right coronary cusps. Initially no aortic insufficiency
(AI) was visualized. However, after initiation of cardiopulmonary bypass
and removal of the Impella, AI of mild severity was identified
(Figure1). Two separate AI jets were present, larger central jet and a
smaller jet in the location previously occupied by the Impella device.
Methods
We chose to repair the aortic value in the operating room as previously
described using a HAART 300 19mm ring (Figure2). The non-coronary
leaflet had a minor leaflet prolapse with mild damage to its node of
Arrhenius which was corrected by two leaflet edge plication sutures of
7-0 prolene.(5) Additionally, a surgical RVAD was placed. We clamped the
aorta, delivered cardioplegia, did the aortic valve repair and the LVAD
graft anastomosis to the ascending aorta during one cross-clamp period.
The cardiopulmonary bypass time was 196 minutes, and the aortic
cross-clamp time was 96 minutes. After AV repair and LVAD implantation,
TEE revealed a well seated annuloplasty ring and trivial AI with a small
central jet (Figure 1). The AV leaflets did not open during systole
postoperatively so a postoperative gradient could not be obtained.
IRB deemed not applicable per the University of Iowa IRB Standard
Operating Procedures and Researcher Guide: 12.G Case Reports: A
case history, case report or case study which are published and/or
presented at national or regional meetings are not considered research
if the case is limited to a description of the clinical features and/or
outcome of a three or fewer patients and do not contribute to
generalizable knowledge.
Results
In summary, we report the first use of the HAART aortic valve repair to
address AI at LVAD placement. The patient had multiple previously
described risk factors for AI development. In doing so we were able to
perform a durable repair of the value without either surgical closure of
the valve or its replacement. We plan to follow this patient serially
and consider repair in future patients with AI requiring LVAD.
Financial Conflict of Interest: None
IRB approval: N/A
Author’s Contributions:
A. Singhal, J. Bang, A. Panos, A. Feider, S. Hanada, J. Rankin were
involved in the design and analysis of the case, the original draft, and
revised drafts of the paper and gave final approval of the version to be
published.
References:
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al. Aortic Insufficiency After Left Ventricular Assist Device
Implantation: Predictors and Outcomes. Ann Thorac Surg.
2020;110(3):836-43.
3. Schechter MA, Joseph JT, Krishnamoorthy A, Finet JE, Ganapathi AM,
Lodge AJ, et al. Efficacy and durability of central oversewing for
treatment of aortic insufficiency in patients with continuous-flow left
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Treatment With Impella Increases the Risk of De Novo Aortic
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