Concomitant Valve-In-Valve Transcatheter Aortic Valve Replacement and Left Ventricular Assist Device Implantation

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: End-stage heart failure requiring left ventricular assist device (LVAD) (n=15267). Intervention: Concomitant aortic valve (AoV) replacement vs. No aortic valve procedure. Primary outcome: Early (≤90 days post-LVAD surgery) survival (HR 1.477, 95% CI 1.154-1.890, p=0.002).

Q: What does this research mean for the field?

Concomitant valve-in-valve transcatheter aortic valve replacement and left ventricular assist device implantation is a feasible, less-invasive alternative to redo surgical aortic valve replacement that minimizes myocardial ischemic injury. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.NEUTRAL.

Takashi Murashita; David L. Joyce; Alberto A. Pochettino; John M. Stulak; Lyle D. Joyce

doi:10.1097/imi.0000000000000360

March 1, 2017Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery

Concomitant Valve-In-Valve Transcatheter Aortic Valve Replacement and Left Ventricular Assist Device Implantation

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Key result

Concomitant AVR during LVAD implantation is linked to ~48% higher early mortality.

HR 1.477
95% CI 1.154-1.890
P=0.002
n=15,267

Why the study?

Redo aortic valve replacement performed simultaneously with LVAD implantation carries potential for increased mortality, and no reports exist on concomitant valve-in-valve transcatheter AVR and LVAD implantation.

Key Points

To describe the feasibility of performing concomitant valve-in-valve transcatheter aortic valve replacement and left ventricular assist device implantation in a patient with severe bioprosthetic valve failure.
A patient presenting with severe aortic prosthetic valve deterioration, moderate aortic regurgitation, and severe left ventricular dysfunction (ejection fraction, 11%) underwent redosternotomy.
Valve-in-valve transcatheter aortic valve replacement was deployed via the ascending aorta, followed immediately by left ventricular assist device implantation.
Concomitant transcatheter aortic valve replacement and device implantation were completed successfully, resulting in an uneventful postoperative course.
The direct transaortic transcatheter approach provided an effective alternative to reoperative open surgical valve replacement while minimizing myocardial ischemic injury.

Study Design

Type

Cohort (n=15,267)

Multicenter

Yes

PICO

P

Population

15,267 adult patients with end-stage heart failure undergoing primary implantation of a continuous-flow LVAD, evaluated via the IMACS Registry worldwide, followed for a median of 13.2 months.

E

Exposure / Comparator

Concomitant aortic valve (AoV) replacement vs No aortic valve procedure

O

Primary Outcome

Early (≤90 days post-LVAD surgery) survival — HR 1.477 (1.154-1.890), p=0.002

Main Result

Hazard Ratio: 1.477 (95% CI 1.154–1.89)

Absolute Event Rate: 85.1% vs 90.4%

p-value: p=0.002

Limitations

Retrospective nature with potential missing data and data entry errors.
Lack of LVAD brand information due to data anonymization in the research database.
Absence of granular data detailing why surgeons elected to perform AoV replacement versus repair.
The degree of AoV regurgitation was graded by local sites without an independent core echocardiography laboratory.
The registry database did not discriminate between AoV repair and AoV closure techniques.

Ask about this paper

Answers are grounded in this paper and cite their sources.

Implication

May warrant caution with concomitant surgical AVR in LVAD patients; leaves open whether transcatheter alternatives reduce this risk.

Abstract

Redo aortic valve replacement (AVR) performed simultaneously with left ventricular assist device (LVAD) implantation carries potential for increased mortality rates. Although transcatheter AVR has been used for patients with previous LVAD placement, no literature reports concomitant valve-in-valve transcatheter AVR and LVAD implantation. Our patient had severe aortic prosthetic valve deterioration and advanced heart failure. Given the risks associated with reoperative aortic valve surgery, we chose transcatheter AVR at the time of LVAD implantation. Transthoracic echocardiography results showed severe aortic prosthetic valve deterioration with moderate aortic regurgitation as well as severe left ventricular dysfunction (ejection fraction, 11%). After redosternotomy, we performed transcatheter AVR via the ascending aorta and subsequent LVAD implantation. The postoperative course was uneventful. Generally, patients with structural deterioration of a bioprosthetic valve who report for LVAD therapy present considerable challenges to the surgeon. Concomitant transcatheter AVR offers a less-invasive alternative to surgical AVR that minimizes ischemic injury to myocardium.

Discussion

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Cite This Study

Murashita et al. (2017) conducted a cohort in End-stage heart failure requiring left ventricular assist device (LVAD) (n=15,267). Concomitant aortic valve (AoV) replacement vs. No aortic valve procedure was evaluated on Early (≤90 days post-LVAD surgery) survival (HR 1.477, 95% CI 1.154-1.890, p=0.002). Concomitant aortic valve replacement during continuous-flow LVAD implantation was independently associated with an increased risk of early all-cause mortality compared to no aortic valve procedure.

synapsesocial.com/papers/6ac5e602d4f0548f25357c04 https://doi.org/10.1097/imi.0000000000000360

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Concomitant Valve-In-Valve Transcatheter Aortic Valve Replacement and Left Ventricular Assist Device Implantation

Key Points

Study Design

PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Concomitant Valve-In-Valve Transcatheter Aortic Valve Replacement and Left Ventricular Assist Device Implantation

Key Points

Study Design

PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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