1. 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

2. 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

3. 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.

4. 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.

5. 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.

6. 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

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

8. 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

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

10. 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

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

12. 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

13. 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

14. 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.