Closure of Dedicated TAVR Device for Aortic Regurgitation in LVAD Patients

Figures

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  Figure 1. Baseline Echocardiographic Images for Cases 1 and 2 Case 1: (A and B) The aortic valve is shown in systole and diastole, respectively, demonstrating absent leaflet motion with a central coaptation defect. (C and D) Severe central aortic regurgitation is demonstrated on color Doppler imaging. Case 2: (E and F) The aortic valve is shown in systole and diastole, respectively, demonstrating preserved leaflet motion. (G and I) severe central aortic regurgitation is demonstrated on color Doppler imaging. (H) Continuous-wave Doppler demonstrates regurgitant flow extending beyond diastole and occupying a substantial portion of the cardiac cycle.

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  Figure 2. Case 1: Postimplantation Imaging (A) Postimplantation aortography confirms correct valve positioning. (B-E) Multimodal echocardiographic assessment including (C) color Doppler, (D) M-mode, and (E) continuous-wave Doppler all demonstrate absent transvalvular flow, consistent with hemodynamic valve closure due to insufficient opening gradient.

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  Figure 3. Case 1: Invasive Hemodynamic Pressure Tracings Immediately After JenaValve Trilogy Implantation The red tracing represents aortic pressure, and the blue tracing represents left ventricular pressure. Left ventricular pressure remains consistently below aortic pressure throughout the cardiac cycle, with complete absence of a transvalvular gradient, rendering valve opening hemodynamically impossible.

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  Figure 4. Case 2: Intraoperative Fluoroscopy (A) Intraoperative fluoroscopy showing embolized J-wire fragment visible in the LVAD outflow graft, and (B-E) successful interventional retrieval of the wire fragment using a crossover technique with a snare device via contralateral femoral access. LVAD = left ventricular assist device.

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  Figure 5. Case 2: Postimplantation Imaging (A) Postimplantation aortography. (B and C) Transthoracic echocardiography postprocedure with poorly visualized transvalvular flow on color Doppler and minimal transvalvular gradients.

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  Figure 6. Case 2: Invasive Hemodynamic Pressure Tracings Immediately After JenaValve Trilogy Implantation The red tracing represents aortic pressure, and the blue tracing represents left ventricular pressure. Left ventricular pressure intermittently exceeds aortic pressure during systole, creating brief periods where a transvalvular gradient exists (mean gradient: 3.88 mm Hg), theoretically permitting intermittent leaflet opening.

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  Figure 7. Case 2: Transesophageal Echocardiography at 7- and 10-Month Follow-Up (A and B) TEE at the 7-month follow-up during investigation for bacteremia, demonstrating subtotal valve thrombosis with minimal residual central forward flow. (C and D) TEE at the 10-month follow-up confirming complete thrombotic sealing with no transvalvular flow. TEE = transesophageal echocardiography.

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  Figure 8. Case 2: PET/CT Fusion Image Showing Biodistribution of the Radiotracer (18F-Fluorodeoxyglucose) No focal pathological uptake was identified at the site of the transcatheter aortic valve prosthesis, particularly at the leaflet level (yellow asterisk), excluding endocarditis. PET/CT = positron emission tomography/computed tomography.

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  Visual Summary. TAVR With a Dedicated Device for Aortic Regurgitation in LVAD Patients: Hemodynamic Benefit Despite Aortic Valve Closure (Left) Severe AR in patients with LVAD creates recirculatory flow that compromises LVAD efficiency. (Middle) Transfemoral JenaValve Trilogy implantation eliminates AR and interrupts this detrimental cycle. (Right) Both patients achieved improved LVAD performance and clinical stabilization without embolic events during follow-up. However, device-related complications occurred: functional valve closure without thrombosis in case 1, and progressive thrombotic valve sealing in case 2. The long-term implications of prosthetic valve closure in this unique hemodynamic setting remain uncertain. AR = aortic regurgitation; LVAD = left ventricular assist device.