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Address for reprints: Paul C. Tang, MD, PhD, Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, 5158 Cardiovascular Center, SPC 5864, 1500 E Medical Center Dr, Ann Arbor, MI 48109-5864.
Concomitant valve repair with left ventricular assist device implant can be safe. This is expected to be most beneficial for those with right ventricle dysfunction and for destination indications.
See Commentary on page XXX.
Aortic insufficiency (AI) reduces the efficacy of left ventricular assist device (LVAD) support.
Recently, significant mitral regurgitation (MR) after LVAD implant has been shown to raise pulmonary pressures and worsen right ventricle (RV) function.
Therefore, concomitant valvular repair may maximize the benefits of mechanical support. Comprehensive valve optimization (Figure 1) can reduce hospital readmissions, improve symptoms, and benefit survival.
A 65-year-old man with dilated cardiomyopathy presented with end-stage heart failure with recurrent admissions despite maximal guideline directed medical therapy (institutional review board No. HUM00132895; approved May 12, 2022). Written informed consent for publication of study data was obtained from the patient discussed in this report.
Echocardiography showed an LV end diastolic diameter of 80 mm, LV ejection fraction of 15%, and an enlarged left atrium of 57 mm. Severe MR was present with annular dilatation and leaflet restriction along with severe TR, and moderate AI. RV function was severely reduced with a tricuspid annular plane systolic excursion of 8.4 mm (Video 1). Poor right heart hemodynamic parameters were shown with a right atrial pressure of 16 mm Hg, pulmonary artery pressure of 56/31 mm Hg, cardiac index of 1.7 L/min/m2, pulmonary vascular resistance of 3.95 Wood Units, and pulmonary artery pulsatility index of 1.56. Multidisciplinary evaluation recommended destination LVAD therapy given poorly controlled diabetes.
Triple valve repair strategies in the LVAD setting:
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Cardiopulmonary bypass was established with aortic and bicaval cannulation.
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Air embolism risk was minimized by venting the right superior pulmonary vein into the LV, ascending aorta, and LV apex.
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The HeartMate 3 apical cuff (Abbott) was sutured onto the LV apex, which was then punctured with a blade, dilated, and a floppy pump sucker was passed into the LV cavity for venting.
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After returning the heart to its native position, the aorta was clamped and given AI, cardioplegia was delivered through a retrograde catheter fastened to the coronary sinus ostia with a purse-string. Through an aortotomy, central coaptation (Park) stitches on the aortic valve were placed. After aortotomy closure and de-airing, the aortic clamp was removed with an ischemic time of 30 minutes.
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The mitral valve was then readily visualized through a trans-septal approach given the large left atrium size and competent aortic valve. A 32-mm mitral annuloplasty rigid ring was secured to downsize the annulus. The mitral valve was not tested for competency due to air embolism risk. The risk of residual MR is very low after annuloplasty.
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After closing the atrial septum, a 26-mm tricuspid valve annuloplasty ring was affixed to the tricuspid annulus.
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We then removed an LV core, secured the HeartMate 3, and sewed the outflow graft to the ascending aorta per standard procedures.
We weaned off cardiopulmonary bypass on inhaled veletri as well as moderate doses of inotrope and pressors. HeartMate 3 speed was set at 5300 rpm with a flow of 4.2 L/min. There was no residual AI, MR, or TR at completion of surgery (Video 2). The chest was left open and closed without issue the next day. Following discharge home on postoperative day 17, there were no readmissions or other complications at 6 months follow-up.
Discussion
Valvular pathologies are common in patients presenting for durable LVAD implantation. The prevalence of associated moderate to severe regurgitant valvular lesions are high.
Thus, balancing risk versus benefit of concomitant valve intervention at the time of LVAD implant is an important issue. The clinical influence of valve lesions is expected to increase as advances in LVAD technology allows longer periods of support, particularly with destination therapy indications. Our group intervenes on moderate-severe AI and moderate-severe TR. We repair severe MR if LV internal diameter in diastole is large (approximately ≥7 cm) because significant MR is likely to persist after LVAD implant. Competent valves that promote unidirectional blood flow will reduce upstream pressure transmission and promote native cardiac ejection in parallel to LVAD output.
As illustrated here, concomitant repair of multiple valves can be feasible and safe using strategies to prevent air embolism as well as minimizing aortic crossclamp and cardiopulmonary bypass duration. Establishment of valve competence may most benefit those with significant RV dysfunction and destination therapy indications.
Only aortic valve repair requires aortic clamping. The mitral valve and tricuspid valve can be repaired with a beating heart, thus not incurring ischemic time. Long-term durability of tricuspid and mitral valve ring annuloplasty remains unclear and serial echocardiography is recommended. A comprehensive approach to valve intervention likely has long-term benefits that outweigh surgical risks with appropriate patient selection.
Postoperative transesophageal echocardiogram showing excellent left ventricular assist device (LVAD) inflow orientation with re-establishment of aortic, mitral, and tricuspid competence. Right ventricle dysfunction remains moderate-severe in degree. Video available at: https://www.jtcvs.org/article/S2666-2507(23)00065-2/fulltext.
Postoperative transesophageal echocardiogram showing excellent left ventricular assist device (LVAD) inflow orientation with re-establishment of aortic, mitral, and tricuspid competence. Right ventricle dysfunction remains moderate-severe in degree. Video available at: https://www.jtcvs.org/article/S2666-2507(23)00065-2/fulltext.
References
Cowger J.
Pagani F.D.
Haft J.W.
Romano M.A.
Aaronson K.D.
Kolias T.J.
The development of aortic insufficiency in left ventricular assist device-supported patients.
Supported by National Institutes of Health grants HL164416 and HL166140 to Dr Tang.
Disclosures: The authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
Institutional Review Board approval for study: HUM00132895 (approved April 12, 2022).
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