Transcatheter aortic valve implantation for left ventricular assist device-related aortic regurgitation

Left ventricular assist devices (LVADs) are increasingly used in patients with end-stage heart failure as a bridge to transplantation or as a destination therapy [1]. While a tailored patient selection process, advances in device management, and technical refinements have improved clinical outcomes, the management of LVAD-related complications continues to be challenging in clinical routine. Aortic regurgitation (AR) is a common complication in patients with prolonged continuous flow (CF)-LVAD support [2]. Failure to open the aortic valve can lead to commissural fusion and remodelling of the aortic cusps, which may be further promoted by excessive LV unloading and haemodynamic shear stress from the outflow cannula [1]. Previous studies have reported that up to 20% of patients on CF-LVAD develop ≥moderate AR during the first 2 years of LVAD support depending on patient-related factors, implantation site of the outflow cannula, and type of CF-LVAD [1, 3, 4]. Quantification of AR using traditional echocardiographic parameters can be challenging in LVAD patients since regurgitation can extend to systole and occur during the entire cardiac cycle. Novel echocardiographic parameters, such as peak systolic-to-diastolic velocity ratio and diastolic acceleration of outflow cannula, have been proposed to better correlate with aortic regurgitant fraction in this context [1]. A blind circulatory loop prevents forward flow from increasing during a ramp test, and accelerates a cascade of secondary cardiac damage, leading to impaired end-organ perfusion and recurrent heart failure.