Original article
Adult cardiac
De Novo Aortic Regurgitation After Continuous-Flow Left Ventricular Assist Device Implantation

Presented at the Fiftieth Annual Meeting of The Society of Thoracic Surgeons, Orlando, FL, Jan 25–29, 2014.
https://doi.org/10.1016/j.athoracsur.2014.05.030Get rights and content

Background

Significant aortic regurgitation (AR) after continuous-flow left ventricular assist device (cf-LVAD) placement affects device performance and patient outcomes. This study examined the development of AR and long-term results after implantation of cf-LVADs.

Methods

The study included all patients with no or less than mild AR who underwent HeartMate II (58 [62%]; Thoratec Corp, Pleasanton, CA) or HeartWare (35 [38%]; HeartWare International, Framingham, MA) implantation at our institute from July 2006 to July 2012. Serial echocardiograms were obtained preoperatively, at 1, 3 and 6 months postoperatively, and then at a minimum of 4-month intervals in patients with longer-term support. Kaplan-Meier estimates for freedom from moderate or greater AR were generated. Logistic regression analysis was used to define independent predictors of AR after cf-LVAD implantation.

Results

Median duration of LVAD support was 527 days (25th, 75th: 289, 907; range, 60 to 2,433 days). Mild AR developed in 48 patients (51.6%) over a median duration of 126 days, with progression to moderate AR in 13 (14%) over 493 days and to severe AR in 2 (2.1%) over 1,231 days. The incidence of mild or greater AR was 43.1% in HeartMate II vs 65.7% in HeartWare recipients (p = 0.035). Overall freedom from moderate or greater AR was 94.7% ± 2.6% at 1 year, 86.9% ± 4.5% at 2 years, 82.8% ± 5.9% at 3 years, and 31% ± 16.9% at 4 years. Independent predictors of AR were duration of support (odds ratio, 1.002; 95% confidence interval, 1.000 to 1.004; p = 0.017) and a persistently closed aortic valve (odds ratio, 0.193; 95% confidence interval, 0.097 to 0.382; p < 0.001).

Conclusions

AR is associated with longer cf-LVAD support duration and persistent aortic valve closure. Incidence of moderate or greater AR after cf-LVAD implantation increases significantly after 3 years. The clinical implications of these data may warrant consideration of prophylactic aortic valve replacement at the time of cf-LVAD implantation, particularly with expected longer duration of support and in patients with preexisting AR that is more than mild.

Section snippets

Material and Methods

The Institutional Review Board at our center approved this study and waived the need for individual patient consent.

Results

Median duration of LVAD support was 527 (289, 907; range, 60 to 2,433 days). Mild AR developed in 48 patients (51.6%) over a median duration of 126 days, progressing to moderate AR in 13 (14%) in 493 days and to severe AR in 2 (2.1%) by 1,231 days. Preoperative demographic and baseline characteristics of non-AR and AR groups are presented in Table 1. Patients in the AR group were significantly older, with mean age of 46.2 ± 11.9 years vs 39.9 ± 14.1 years in the non-AR group (p = 0.022). Other

Comment

The principal finding of this study was that the freedom from de novo moderate or greater AR after cf-LVAD implantation decreased sharply after 3 years. Clinical implications of these data may warrant consideration of prophylactic AoV replacement at the time of cf-LVAD implantation, particularly in patients with expected longer duration of support and in patients with preexisting AR that is more than mild.

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