Efficacy and durability of central oversewing for treatment of aortic insufficiency in patients with continuous-flow left ventricular assist devices

Matthew A Schechter; Jeremy T Joseph; Arun Krishnamoorthy; J E Finet; Asvin M Ganapathi; Andrew J Lodge; Carmelo A Milano; Chetan B Patel

doi:10.1016/j.healun.2014.04.017

Efficacy and durability of central oversewing for treatment of aortic insufficiency in patients with continuous-flow left ventricular assist devices

J Heart Lung Transplant. 2014 Sep;33(9):937-42. doi: 10.1016/j.healun.2014.04.017. Epub 2014 May 9.

Authors

Matthew A Schechter¹, Jeremy T Joseph¹, Arun Krishnamoorthy², J E Finet², Asvin M Ganapathi¹, Andrew J Lodge¹, Carmelo A Milano¹, Chetan B Patel³

Affiliations

¹ Department of Surgery, Duke University Medical Center, Durham, North Carolina.
² Department of Medicine, Duke University Medical Center, Durham, North Carolina.
³ Department of Medicine, Duke University Medical Center, Durham, North Carolina. Electronic address: chetan.patel@dm.duke.edu.

PMID: 24997496
DOI: 10.1016/j.healun.2014.04.017

Abstract

Background: Aortic insufficiency (AI) in patients supported with continuous-flow left ventricular assist devices (CF-LVAD) results in regurgitant volume returning from the aorta to the left ventricle, increased LVAD pump volume and reduced systemic cardiac output. One common strategy to address AI during CF-LVAD support is central oversewing of the aortic valve, which allows some opening between the valve leaflets laterally. However, the long-term durability of this technique has not been extensively described.

Methods: All patients who underwent central oversewing of the aortic valve during CF-LVAD support between January 2006 and March 2013 were included in this analysis. Pre- and post-procedure intra-operative transesophageal echocardiograms (TEEs) were reviewed to determine the efficacy of the surgical technique, whereas all subsequent transthoracic echocardiograms (TTEs) were reviewed to assess durability. AI severity was graded using the vena contracta (VC) width and the ratio between the VC and left ventricular outflow tract (LVOT) diameter.

Results: Nineteen patients with central aortic valve oversewing were identified. Median follow-up was 560 days (range 46 to 954 days). All but 1 patient had their aortic insufficiency reduced to "none/trace" on post-operative TEE. There was no statistically significant increase in the VC width and VC/LVOT ratio between the first and last follow-up echocardiograms, and only 2 patients developed more than mild aortic insufficiency after central oversewing. Central oversewing of the aortic valve did not adversely affect outcomes after LVAD implantation.

Conclusion: Central oversewing of the aortic valve is an effective and durable means of addressing greater than mild AI in patients with CF-LVAD.

Keywords: aortic insufficiency; heart failure; left ventricular assist device; mechanical circulatory support; outcomes; treatment.

MeSH terms

Aortic Valve / diagnostic imaging
Aortic Valve / physiopathology
Aortic Valve / surgery*
Aortic Valve Insufficiency / diagnostic imaging
Aortic Valve Insufficiency / physiopathology
Aortic Valve Insufficiency / surgery*
Cardiac Output / physiology
Echocardiography
Follow-Up Studies
Heart Failure / therapy
Heart Valve Prosthesis Implantation / methods*
Heart-Assist Devices*
Humans
Retrospective Studies
Severity of Illness Index
Treatment Outcome