Concomitant Aortic Valve Repair in Patients Undergoing Continuous-flow Left Ventricular Assist Device Placement: A 10-year Experience and Clinical Implications.

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Presentation transcript:

Concomitant Aortic Valve Repair in Patients Undergoing Continuous-flow Left Ventricular Assist Device Placement: A 10-year Experience and Clinical Implications Shinichi Fukuhara1, Koji Takeda1, Jiho Han1, Luilly Vargas, Boyangzi Li, Paolo Colombo2, Paul Kurlansky1, Donna Mancini2, Melana Yuzefpolskaya2, Veli Topkara2, Hiroo Takayama1, Yoshifumi Naka1 1Surgery, Columbia University Medical Center, New York, NY 2Medicine, Columbia University Medical Center, New York, NY

Relevant Financial Relationship Disclosure Statement I will not discuss off label use and/or investigational use of any drugs/devices The following relevant financial relationships exist related to this presentation: Yoshifumi Naka: Thoratec, Consultant All other authors: No Conflicts I have no disclosurs

Background Progression of aortic valve insufficiency (AI) is not uncommon in CF-LVAD-supported patients [1] No universal consensus regarding surgical management of pre-existing AI [2] Jorde UP, et al. Prevalence, significance, and management of aortic insufficiency in continuous flow left ventricular assist device recipients. Circ Heart Fail. 2014;7:310–9. McKellar SH, et al. Durability of central aortic valve closure in patients with continuous flow left ventricular assist devices. J Thorac Cardiovasc Surg. 2014;147:344–8.

Central Aortic Valve Closure (Park’s Stitch) [3] Pros Simple AV is still able to open for ejection Cons Unclear applicability, efficacy and durability acellular, non-crosslinked extracellular matrix (ECM) bioscaffolds with ability of constructive tissue remodelling Park SJ, et al. Management of aortic insufficiency in patients with left ventricular assist devices: a simple coaptation stitch method (Park's stitch). J Thorac Cardiovasc Surg. 2004;127:264-6.

Purpose We have reviewed our 10-year experience of CF-LVAD implantation with and without concomitant AV repair in order to define the clinical efficacy and durability of this technique.

Methods 340 were included in the analysis AV repair 57 (16.8%) No AV repair 283 (83.2%) 360 patients with CF-LVAD implantations from 3/2004 to 5/2014 3 excluded due to Jarvik 2000 implantation via thoracotomy 8 excluded due to concomitant AVR or closure 9 excluded due to previous AV surgery

Surgical Indication/Technique Indications ≥ mild AI Technique Standard CPB Aortic cross-clamp Pledgeted 4-0 prolenes

Baseline Characteristics Variable All (+) Repair (–) Repair p-value Age (years) 56.6 ± 13.9 65.1 ± 8.3 54.9 ± 14.1 < 0.001 Destination therapy (DT) 89 (26.2) 27 (47.4) 62 (21.9) COPD 33 (9.7) 10 (17.5) 23 (8.1) 0.028 BUN (mg/dL) 35.1 ± 20.3 41.9 ± 21.6 33.7 ± 19.7 0.005 HM II Risk Score 1.61 ± 0.92 2.09 ± 0.80 1.50 ± 0.93

Baseline AI Significantly different baseline AI p < 0.001 severe mild mod-severe mod trace mild-mod Significantly different baseline AI mild none trace

Operative Data CPB time (min) 94.4 ± 48.1 112.3 ± 44.2 90.7 ± 48.1 Variable All (+) Repair (–) Repair p-value CPB time (min) 94.4 ± 48.1 112.3 ± 44.2 90.7 ± 48.1 0.002 Cross clamp time (min) N/A 23.3 ± 9.9 Transfusions (units) PRBC FFP PLT 1.6 ± 2.5 2.9 ± 2.7 9.4 ± 7.4 2.5 ± 2.8 3.8 ± 2.9 11.1 ± 6.5 1.4 ± 2.4 2.7 ± 2.6 9.0 ± 7.5 0.009 0.006 0.051 Vasoactive-inotropic score 22.9 ± 22.1 26.5 ± 13.3 22.1 ± 13.7 0.044

On-device Survival Blue: No Repair Red: Repair 65.2 ± 9.4 VS 77.8 ± 3.4%

Freedom from Significant AI Red: Repair Blue: No Repair Red: Repair Blue: No Repair 66.7 ± 8.9 VS 59.9 ± 5.1% 78.1 ± 8.7 VS 41.8 ± 8.3% Entire Cohort Destination Therapy Cohort

Surgical Re-intervention Variable All (+) Repair (–) Repair p-value Reintervention AV repair AVR AV closure Amplatzer Transplant 12 (3.5) 5 (1.5) 1 (0.3) 4 (1.2) 1 (1.8) 11 (3.9) 5 (1.8) 1 (0.4) 3 (1.1) 0.67 Failed Repair

Conclusions On-device survival was similar despite the significant difference in baseline risk profiles. The prevalence of significant AI was comparable between groups despite the significant difference in baseline pre-existing AI. The efficacy of repair was more evident among DT patients.