Surgical closure of left ventricular outflow tract after left ventricular assist device implantation in patients with aortic valve pathology.

BACKGROUND

In patients with refractory heart failure, aortic valve (AV) insufficiency or the presence of a prosthetic AV has been considered a relative contraindication to left ventricular assist device (LVAD) therapy. Nevertheless, we have successfully implanted LVADs in 5 patients with native AV insufficiency or an AV prosthesis by closing the left ventricular outflow tract (LVOT).

METHODS

The method of LVOT closure was tailored to the patients' differing circumstances. Patient 1 had a regurgitant tri-leaflet native AV. Patient 2 had undergone previous aortic root reconstruction with a porcine bioprosthesis. Patient 3 had a congenitally bicuspid AV with significant insufficiency. Patient 4 had a native tri-leaflet valve that developed thrombus and insufficiency after previous LVAD placement. Patient 5 required removal of a recently placed mechanical AV. Accordingly, the LVOT was closed with a bovine pericardial patch in Patients 1, 4 and 5, and the lines of coaptation of the AV leaflets were closed primarily in Patients 2 and 3.

RESULTS

Four months post-operatively, 1 patient underwent heart transplantation; on removal of the heart, LVOT patch integrity was confirmed visually. After a follow-up period of 6 months to 2 years, the remaining 4 patients are in New York Heart Association Functional Class I while awaiting cardiac transplantation. Transesophageal echocardiography has confirmed persistent LVOT closure.

CONCLUSION

In all 5 cases, LVOT closure circumvented the challenges associated with LVAD therapy in the presence of native AV insufficiency or an AV prosthesis.