Transcatheter Strategies to Eliminate Aortic Regurgitation in LVAD Patients: A Case Series

Objectives: The development of aortic regurgitation (AR) is a common side effect related to prolonged continuous-flow left ventricular assist device (cf-LAVD) therapy. Its progression leads to heart failure-related symptoms and significantly increased mortality. No minimally invasive option to treat native-valve AR in this patient population is well established. This study sought to investigate the value of transcatheter aortic valve implantation (TAVI) as a potential treatment option for severe AR in patients with cf-LVAD.

Methods: From 2010 to 2018, 11 patients with severe AR during follow-up after cf-LVAD implantation were identified. Periprocedural outcome was defined according to Valve Academic Research Consortium (VARC) II criteria. Furthermore, LVAD and transcatheter heart valve thromboses as well as mortality during follow-up were assessed. Due to the small sample size, statistical analyses were limited to descriptive statistics.

Results: The median time interval from LVAD implantation to TAVI was 1.7 years (interquartile range [IQR]: 1.0–3.1). The median EuroSCORE II was 20.6% (IQR: 9.5–40.7), median age was 62 years (IQR: 58–69), and 82% (n = 9) of patients were male. One patient was an emergency case. Aortic valve interventions were performed either through transfemoral (n = 9), transapical (n = 1) or transaxillary access (n = 1). Two CoreValve, one Lotus Valve, one Sapien XT, and seven Sapien 3 THVs were used. Device success according to VARC II criteria was achieved in 54% (n = 6) with need for second valve as the reason for device failure. However, AR at discharge was none/trace for all patients. No stroke and no procedure-related mortality occurred. In-hospital death occurred in 18% (n = 2). During a median follow-up time of 246 days (IQR: 19–402), 54% (n = 6) of patients died and 36% (n = 4) suffered from Valve or LVAD thrombosis.

Conclusion: TAVI for severe native valve AR in cf-LVAD patients eliminates AR in all patients. However, due to complex anatomy, in almost half of the patients, second valve was necessary to eliminate AR. Taking into account the high baseline risk and the lack of true alternative options, the TAVI procedure is justified for these patients.