Development of Aortic Insufficiency in Patients Supported With Continuous Flow Left Ventricular Assist Devices

Abstract

Development of aortic insufficiency (AI) in patients supported with continuous flow left ventricular assist devices (LVAD) can adversely affect pump performance. In this study, we examined the incidence of new AI after LVAD implant at our institution. Pre- and postoperative echocardiograms of 66 patients who received HeartMate II or Heartware LVAD at our institution since June 2008 were reviewed for presence of new AI. Median LVAD support duration was 221 days. New AI developed in 6 patients (9.5%) after a median time of 374.5 days of support. There were no cases of severe or symptomatic AI. There was no significant difference between the AI incidence between HeartMate II and Heartware recipients. For patients who remained on LVAD support at 6 and 12 months, freedom from AI was 100% and 68.4%, respectively. Age, destination therapy status, and duration of support were predictors of new AI after LVAD implant. In conclusion, AI develops frequently during long-term support with continuous flow LVADs, particularly in those supported for longer than 6 months. As we move to the era of long-term LVAD support and destination therapy, further studies with longer follow-ups are required to determine the progression and clinical significance of AI in these patients.

Prevalence, Significance, and Management of Aortic Insufficiency in Continuous Flow Left Ventricular Assist Device Recipients

“…7,10 Although some of our data are obtained retrospectively and with the additional caveat of difficulty in grading AI, this concordance with the published literature on early (1 year) AI development should provide significant reassurance that our novel long-term observation of at least moderate AI in nearly one third at the 3-year time point is not an institutional idiosyncrasy. Similarly, our data are in line with the growing body of severe AI case reports.…”

“…Similarly, in a cohort of 53 HM II patients, Cowger et al 7 demonstrated near-identical prevalence of greater than mild de novo AI at 1 year and a trend toward progression of AI with increased duration of CF-LVAD support. A more recent study by Soleimani et al 10 reported the occurrence of greater than mild de novo AI in 31.6% of patients at 1 year. Notably, neither Cowger et al 7 nor Soleimani et al 10 reported any cases of severe AI and the need of surgical correction in their HM II cohorts after mean total support times of 239 and 336.5 days, respectively, although the number of case reports describing percutaneous and surgical intervention for severe AI in the literature is increasing.…”

“…A more recent study by Soleimani et al 10 reported the occurrence of greater than mild de novo AI in 31.6% of patients at 1 year. Notably, neither Cowger et al 7 nor Soleimani et al 10 reported any cases of severe AI and the need of surgical correction in their HM II cohorts after mean total support times of 239 and 336.5 days, respectively, although the number of case reports describing percutaneous and surgical intervention for severe AI in the literature is increasing. 3 Our findings in the current study are not only concordant with the reported findings on lower grade AI but also constitute a significant extension of previous work given cohort size, time of observation, and resultant new insights on prevalence, possible prevention, and management of clinically significant AI.…”

Aortic Valve Pathology in Patients Supported by Continuous-Flow Left Ventricular Assist Device

“…In contrast, Soleimani et al reported that 0/8 patients (0%) developed AI at a mean of 158 days with the HVAD vs. 6/55 (10.9%) with the HM-II at a mean of 314 days. 11 Higher flow pulsatility and afterload sensitivity of the centrifugal pumps helps to avoid the less frequent opening of the aortic valve experimentally. 12, 13 Longer Sinus Wall, Tubular Aorta and Aortic Root The examined aortic wall, an extension of the left coronary cusp of the aortic valve, was obtained from the left posterolateral aspect of the aortic wall.…”

Preoperative Prediction of Aortic Insufficiency During Ventricular Assist Device Treatment

“…18) Since then, a number of single-center studies have documented a wide-ranging prevalence of AI during LVAD treatment. 15,[19][20][21] The development of AI during LVAD treatment is considered to be a multifactorial phenomenon and a result of altered AV and aortic root biomechanics due to chronic and continuous ventricular unloading. Unloading of LV results in ventricular decompression, and the combination of systolic dysfunction and low preload cannot generate sufficient pressure to open the native AV.…”