Transcatheter Aortic Valve Implantation (TAVI) in Left Ventricular Assist Device (LVAD) Patients with Aortic Valve Insufficiency: A Word of Caution

Objectives: Transcatheter aortic valve implantation (TAVI) is a well-accepted therapy for severe aortic valve stenosis in a population at high-risk for conventional operation. Some TAVI valves can be used in aortic valve insufficiency, too. However, the overall experience of TAVI valves in patients with aortic valve insufficiency is limited. Especially, in patients with acquired aortic valve insufficiency after long-term left ventricular assist devices (LVAD) implantation.

Methods: We report about a case of TAVI implantation in a patient with acquired aortic valve insufficiency after LVAD support and show the severe TAVI related procedural complications.

Results: A HeartWare HVAD LVAD was implanted in a 68-year-old female with end-stage dilated cardiomyopathy with NYHA IV. 4 years after the initial implantation an aortic valve insufficiency grade II-III was seen in echocardiography with an increase from NYHA II to III. Different approaches with LVAD rpm in- and decrease over the next weeks did not show an improvement in functional status, that a transfemoral TAVI approach was planned. During the procedure a 29 mm Medtronic CoreValve was implanted. During implantation paravalvular leakage was seen, which however could not confirmed by echocardiography. 12 hours later the patient developed a severe cardiogenic shock with high doses of inotropes and renal failure. In the echocardiography a severe paravalvular leakage was seen and the patient was brought in the hybrid-OR again for an emergency valve-in-valve procedure. Via transfemoral access a 29 mm Medtronic CoreValve® was implanted as valve-in-valve. Post procedure the paravalvular leakage was even higher that an emergency re-operation was performed. During the operation both CoreValves were extracted and the aortic valve was closed with a park stitch. The postoperative course was prolonged due to the previous cardiogenic shock. 2 month after the operation the patient could leave the hospital in NYHA class II.

Conclusion: Aortic valve insufficiency after long-term continuous flow LVAD-implantation is a known pathology which is difficult to be addressed. Transapical TAVI is not possible. However the TAVI approach could be complicated especially in LVAD supported patients, because due to the suction of the apical implanted assist device a small paravalvular leakage has a tremendous impact. A planned reoperation with an aortic valve closure or replacement might be the better opportunity in LVAD supported patients.

 

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