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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3795_Библиотеки_им_академика_М_И_Перельмана
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Management of Aortic Valve Disease in LVADs
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symptoms. Ramp testing under echocardiographic guidance is the next non-invasive step in
managing symptomatic patients. Those who do not respond to RPM optimization under
echocardiographic guidance should undergo right heart catheterization [22] with concomitant
echocardiographic direction. An initial increase in RPM could be trialed with the aim of
increasing cardiac output and improving organ perfusion. However, it should not be
underestimated that an increase in RPM can result in a worsening aortic valve insufficiency.
This approach can only be considered as a short-term palliative strategy. If medical therapy
and adjustments to the pump are unsuccessful, invasive procedures should be considered and
candidates for a heart transplant could be inserted in an emergent transplant list. There are no
absolute recommendations for the most appropriate surgical procedure for these patients.
Surgical options include:
1) Implantation of an aortic patch [24, 25]
2) Replacing the native aortic valve with a biological valve
3) Partial closure of the aortic valve
4) Transcatheter aortic valve replacement (TAVR)
5) Implantation of an aortic valve occluder
Complete closure of the LV outflow tract completely eliminates the risk of AI but can
lead to a disastrous scenario if a device malfunction occurs. If heart function recovery is
expected to occur, the closure of the aortic valve is absolutely contraindicated [26]. In this
case, valve replacement or repair could be considered. The surgical approaches that require a
sternotomy carry higher risks than less invasive options, including possible ventricular
damage and risk of hemorrhage, and are burdened by an up to 18% short-term mortality and
up to 7% late mortality [27, 28]. The percutaneous approach in patients with contraindications
to surgery reduces the risk related to general anesthesia, extracorporeal circulation, and the
effect of anticoagulation. Percutaneous treatments include implantation of an occlusion
device, which blocks the ventricular outflow tract, or implantation of a transcatheter aortic
valve prosthesis (TAVR). Implantation of an occlusion device reduces AI from severe to mild
without changing LVAD parameters. However, this procedure is not without complications.
In fact, cases complicated by device migration [29] have been described. Long-term
consequences of aortic valve occlusion by implanting an occluder have not yet been well
studied. In our experience, we reported the strategy carried out in a patient implanted with
Heartmate II (Chicago, IL, USA) and admitted with severe signs of heart failure related to the
late development of AI. The patient, not eligible for a heart transplant, was considered
unsuitable for percutaneous valve implantation because an aortic root diameter larger than 40
mm was estimated. The only alternative was the occlusion of the aortic valve by implanting
an oversized occluder [30]. The postoperative echocardiographic evaluation displayed an
aortic regurgitation decreased from severe to trivial (Figure 1).
The chest tomography conducted after seven days demonstrated the device was well
positioned (Figure 2).
The second option, TAVR, has shown an excellent efficacy in the treatment of AI in
patients implanted with LVAD. The advantage of this procedure is that, unlike the occlusion
of the AV, the patient is not entirely dependent on mechanical support. If a device
malfunction or thrombosis occurs, transaortic flow through the valve prosthesis is maintained
by the residual left ventricular function. Problems associated with this procedure include the
A. Montalto, C. Amarelli, K. Hopkins et al.
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risk of perivalvular leaks and the difficulties of anchoring the prosthesis in good position.
Unbehaun et al. described a procedure of transcatheter valve prosthesis implantation,
preceded by implantation of a bare metal stent in the aortic root, in order to prepare a land
zone for the valve prosthesis to mitigate this latter issue [31].
Figure 1. Placement of the Amplatzer patent foramen ovale multi-fenestrated 35-mm device (St Jude
Medical, Saint Paul, MN) on the aortic valve with fluoroscopy.
Figure 2. Computed tomographic images of the device after implantation. (A) Coronal view. (B) Axial
view.
ASSESSMENT AND INDICATION FOR TREATMENT OF AORTIC
REGURGITATION AT THE TIME OF LVAD IMPLANTATION
An exhaustive functional and morphological evaluation of the aortic valve should be part
of the screening process in patients evaluated for LVAD implantation. It is essential that the
AV is assessed under physiological conditions to avoid underestimating the degree of AI
when the patient is already under general anesthesia. AI before the LVAD implantation is
defined and quantified in the same way as for any other non-VAD patient, namely by preoperative transthoracic echocardiography followed by transesophageal echocardiography
immediately before the surgical procedure and when cardiopulmonary bypass (CPB) is
Management of Aortic Valve Disease in LVADs
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instituted. Because LVAD candidates often have high ventricular filling pressures, a
condition can lead to underestimating the AI grade, a further estimate is made after
extracorporeal circulation is initiated when the left ventricle has been drained through a vent
in the pulmonary vein. This situation reproduces the physiology of the support with LVAD
and allows a better definition of the degree of aortic regurgitation. Because the severity of
aortic insufficiency progresses in at least 25% of cases and the known negative hemodynamic
effect and the clinical consequences that the development of AI entails, it is recommended to
proceed with the treatment of moderate or greater aortic regurgitation and the support time is
expected to be more than one year [22, 26]. According to data from the INTERMACS
registry, 3% of patients underwent a combined aortic valve procedure at the time of LVAD
implantation [32]. In a retrospective study of 281 patients, Pal et al., reported a 4% prevalence
of moderate or severe AI before LVAD implantation [33]. Patients with moderate AI and risk
factors predisposing to AI development during LVAD support (family history, sex, age > 60
years, low body surface area, ischemic cardiomyopathy) should be considered for an aortic
valve procedure at the time of implantation of the LVAD. This indication is particularly valid
when prolonged support is assumed or when the patient is a candidate for DT. Based on the
ISHLT guidelines, patients with aortic valve stenosis of any degree associated with moderate
insufficiency must be considered for valve replacement surgery by using a biological
prosthesis (class I level of evidence C). Patients with severe stenosis should have SVA
regardless of the degree of aortic regurgitation (class II level of evidence C) [26].
STRATEGIES FOR AV REPAIR AT TIME OF LVAD IMPLANTATION
The choice of the surgical procedure for AV repair should be based on the patient's
surgical risk, the AI mechanism, the valve and aortic root anatomy, and the support duration.
There is currently no worldwide consensus about the most effective and appropriate
procedure [22]. In an INTERMACS study conducted on 5344 patients with a CF-LVAD, the
most common procedure performed on a malfunctioning aortic valve during LVAD
implantation was valve closure (2.3%). Valve replacement was performed in 1.6% of cases. A
technique for repairing the valve in which a stich is used to approximate aranzio nodules has
been described by Park et al. (Figure 3).
This method is possible when the valve flaps are not overly thin or fragile. The advantage
of this technique is to allow blood to be ejected through the aortic valve. The durability of this
approach over time remains to be evaluated. Many studies have shown that adverse events
and survival rates were similar between patients with and without closure of the AV at the
time of VAD implantation [34, 35, 36, 37]. Jorde et al. reported a recurrence rate of 2.3% at
one year for mean AI, 2.3% for severe, moderate AI, 2.3% for severe AI and a two-year AI
freedom of 66% after the Park stitch was used [20]. The effectiveness and duration of the
stitch seem to be most beneficial in DT patients or in patients with risk factors for AI, with a
69% reduction in the risk of developing AI when compared with patients without AV stitch.
The analysis conducted by Robertson et al. on INTERMACS databases, revealed a moderate
to severe AI progression of 18% at 12 months after aortic valve repair in conjunction with the
LVAD implant [35] (Figure 4).
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Figure 3. Park stitch: pledgeted 4-0 Prolene sutures are applied to approximate the 3 nodules of
Arantius to create a coaptation stitch. Reproduced from Park et al. with permission from Elsevier.
Figure 4. Post-operative recurrence of moderate to severe aortic insufficiency by type of AV procedure
performed.
One method to mitigate this risk is by partial closure of the AV with the modified Park
technique consisting of additional 5-0 prolene mattress sutures on each side placed between
the central point and the commissures to strengthen and reduce the tension on the central
point. This technique can be used in cases of degenerated AV with important prolapse or
when the aortic leaflets are very fragile. While this allows blood to pass through the AV, the
risk of stenosis is greater (Figure 5). A comparison of this technique to the single central point
and its durability has yet to be conducted.
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Note: evolved technique, described by Adamson, which incorporates three felt strips rather than
individual pledges to expedite closure of the valve.
Figure 5. Native aortic valve closure technique.
Figure 6. Survival by type of AV procedure performed.
Another treatment strategy is the complete closure of the left ventricle-aorta junction.
Two main techniques have been described: 1) direct closure of the native AV with the use of
felt strips along the free edge of the flaps; 2) positioning a circular patch of Dacron, GoreTex, autologous or heterologous pericardium directly on the native annulus or to the
prosthesis ring if already implanted [27]. Total closure of the AV is associated with a low
incidence of AI recurrence. However, this technique leaves the patient totally dependent on
the device and events such as pump thrombosis can have devastating results. Moreover, this
technique is contraindicated if recovery of myocardial function is expected [22]. Two
important studies that analyzed the outcome after AV procedures provide mixed results [35,
38]. Using the data of the Heartmate 2, pivotal trials for patients with BTT and DT
indications, John et al. found that patients with concomitant AV procedures (n = 80 patients,
divided into AV repair [n = 18], closure [n = 32], and replacement [n = 30]) were sicker and
had higher early mortality and right ventricular failure rates. In that study, 30-day mortality
was lowest for AV closure (6.3%), followed by AV replacement (13%), and finally AV repair
(18%). Survival rates at 1 and 2 years were also lower after AV closure than after AV repair
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or replacement (84.1% vs 70.9% for closure, 75% vs 57% for repair, and 64% vs 43% for
replacement, respectively; P <0.001) [38]. In an INTERMACS database analysis (n = 305
patients, divided into AV repair [n = 125], closure [n = 95], and replacement [n = 85]),
Robertson et al. reported increased mortality associated with complete over-sewing of the
valve, with most deaths occurring early after the procedure [35] (Figure 6).
One-year survival was lower after AV closure compared with AV repair or replacement
(81% for patients who did not undergo an AV procedure, 79% for patients who underwent an
AV repair, 72% for patients with an AV replacement, and 64% for those with AV closure (P
1⁄4 0.003)). Even if it is unclear whether the deaths were related to the AV closure, complete
over sewing has become less popular. This technique is now mainly used when a mechanical
valve is already in place to avoid a redo AV replacement with the use of a bioprosthesis.
An additional option for treatment of AI is aortic valve replacement with a biological
prosthesis. This procedure is indicated when the aortic valve is calcified or stenotic or when a
partial closure does not provide satisfying results. Its potential benefits must be weighed
against the risks of an extended clamping time. The duration and superiority of valve
replacement when compared with AV over-sewing are unknown. In the INTERMACS
analysis, one year after AV replacement at the time of LVAD implantation, survival was
72%, and non-recurrence of AI was observed [35]. Many authors encourage valve
replacement with bioprosthesis, especially in stable and long-term supported patients, such as
DT. However, the fusion of the cusps, fibrosis, subvalvular thrombosis and obstruction have
been reported early after LVAD implantation [39, 40]. Furthermore, abnormal loading
conditions cause an increased probability of prosthtesis dysfunction. If a biological prosthesis
has been implanted for more than five years or has signs of deterioration, it is advisable to
over-sew the valve [22]. In addition with the increase in availability of the transcatheter valve,
in the future, it is conceivable that the recommendation will be to use TAVR for the de novo
treatment of AI in patients implanted with LVAD. Many reports, albeit with a limited number
of patients, have demonstrated the feasibility of TAVR in the case of AI in patients supported
with LVAD, both in cases of native AV and in degenerated bioprosthetic valves [41, 42, 43].
The use of mechanical prostheses in an aortic position is highly discouraged given the high
thromboembolic risk. If a mechanical valve was already in place, the recommended choice is
to replace the mechanical valve with a bioprosthesis or to over-sew the valve with a patch.
CONCLUSION
The presence of acute valvular heart disease in patients with end-stage heart failure
presenting for CF-LVAD consideration is frequent. Previously, there has been a lack of
understanding and consensus on the adverse impact of VHD on patients receiving LVAD
therapy. Recent evidence demonstrates more consistent findings of an adverse impact of
valvular pathologies on the hemodynamic benefit of CF- LVAD support, leading surgeons
and cardiologists to advocate for more aggressive surgical correction. This is particularly true
for AI. Safe and straightforward surgical approaches, such as partial central AV closure, are
being used with satisfactory results.
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