First Implant Of A Edwards Resilia Insipiris Bioprosthesis For The Treatment Of Aortic Regurgitation In A Lvad Patient
Andrea Montalto, Antonio Lio, Federico Ranocchi, Francesca Nicoḷ, Marina Comisso, Francesco Musumeci.
Azienda Ospedaliera San Camillo Forlanini, Rome, Italy.
Background: We report the first implant of a new class of bioprosthetic aortic valve (AV) created with RESILIA tissue (Edwards Lifesciences LLC, Irvine, CA, USA) in a Left Ventricular Assist Device (LVAD) patient.Methods:In November 2018, a 58-year-old man was referred to us for LVAD implantation due to end-stage heart failure as a result of an idiopathic dilated cardiomyopathy. Due to his comorbidities, LVAD implantation was planned as a destination therapy. Preoperative echocardiography showed severe tricuspid regurgitation and a moderate-to-severe aortic incompetence (AI) due to leaflet fibrosis and retraction. After a standard sternotomy, cardiopulmonary bypass (CPB) was instituted with aortic and bicaval cannulation. The AV was approached first through a transverse aortotomy: the native valve was replaced with a 21 mm Edwards Resilia Inspiris bioprosthesis. Then, tricuspid valve annuloplasty was performed and finally, after declamping, a third generation LVAD was implanted.Results:The aortic cross-clamp time and CPB times were 75 and 230 minutes, respectively. A temponary right ventricular assist device was utilized for weaning from CPB. Postoperative echocardiography showed a closed and competent aortic bioprosthesis. Conclusion:In the presence of an LVAD, AI leads to a blind circulatory loop, with a portion of LVAD output regurgitating through the AV into the left ventricle and back again through the device, limiting effective forward flow and leading to organ malperfusion and increased left ventricular diastolic pressures. Therefore, repairing or replacing the AV is advisable. In young patients with a LVAD as a destination therapy, a durable bioprosthetic valve is needed: RESILIA tissue is a bovine pericardial tissue that incorporates a novel preservation technology, which reduces the accumulation of calcium. Moreover, in patients with LVAD undergoing heart transplantation, there is evidence of commissural fusion of bioprosthetic leaflets, that may result in AI. The frame of the Resilia Inspiris valve is designed to be compliant at the orifice as well as at the commissures. The compliance of the commissure supports is intended to reduce the loading shock at the valve commissures and free margin of the leaflets. In conclusion, in young LVAD patients, Resilia Inspiris bioprosthesis, due to its features, is a good option to treat AI.
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