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Severe Aortic Regurgitation during LVAD assist; “Closing the Door for Ever”
Hartmuth B. Bittner, Bradford Ledzian, Rohit Bhtheja.
Florida Hospital Transplant Institute, Orlando, FL, USA.

OBJECTIVE: Aortic insufficiency (AI) is increasingly recognized as a complication of continuous flow left ventricular assist device (CF-LVAD) support and may lead to clinical decompensation requiring correction. The incidence of “de novo” AI in patients supported with the CF-LVAD Heartmate II is greater than 25%.
METHODS: In this worst case scenario, we present a patient status post Heartmate II implamtation as a third time redo sternotomy for ischemic cardiomyopathy complicated by de novo aortic insufficiency. He underwent coronary bypass surgery in 2002 with redo surgical revascularization in 2010. At 11 months postimplant, this 74 year old hard working architect presented with severe right and left heart failure, multi-organ dysfunction, and hepato-renal failure. Multiple echocardiograms revealed an opening aortic valve and near normal right ventricular function in the past.
RESULTS: Six weeks ago, when the worsening AI was diagnosed, the decrease of Heartmate II CF-LVAD flow through decreasing the rounds per minute (RPM) from 8800 RPM to 8200 RPM attenuated the AI markedly. Ultimately, the patient underwent percutaneous, transcatheter closure of the aortic valve (see echo and heart catheter images and video) with an multi-fenestrated 30 mm Amplatzer Cribiform closure device. Under echocardiography the flow of the CF-LVAD was increased to 9400 RPM. Two weeks post procedure, the patient remains stable with improved symptoms and functional status, and without evidence of further aortic insufficiency or device migration.
CONCLUSIONS: Percutaneous transcatheter closure of the aortic valve effectively treats LVAD-associated AI and reduces pulmonary capillary wedge pressure. This procedure should be considered to treat LVAD-associated AI in patients who are poor candidates for repeat operation and catheter-based aortic valve procedures.

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