Replacement of the aortic valve with a bioprosthesis at the time of continuous flow ventricular assist device implantation for preexisting aortic valve dysfunction

Special Considerations for Advanced Heart Failure Surgeries: Durable Left Ventricular Devices and Heart Transplantation

Heart transplantation and durable left ventricular assist devices (LVADs) represent two definitive therapies for end-stage heart failure in the modern era. Despite technological advances, both treatment modalities continue to experience unique risks that impact surgical and perioperative decision-making. Here, we review special populations and factors that impact risk in LVAD and heart transplant surgery and examine critical decisions in the management of these patients. As both heart transplantation and the use of durable LVADs as destination therapy continue to increase, these considerations will be of increasing relevance in managing advanced heart failure and improving outcomes.

Concomitant Valve-In-Valve Transcatheter Aortic Valve Replacement and Left Ventricular Assist Device Implantation

Redo aortic valve replacement (AVR) performed simultaneously with left ventricular assist device (LVAD) implantation carries potential for increased mortality rates. Although transcatheter AVR has been used for patients with previous LVAD placement, no literature reports concomitant valve-in-valve transcatheter AVR and LVAD implantation. Our patient had severe aortic prosthetic valve deterioration and advanced heart failure. Given the risks associated with reoperative aortic valve surgery, we chose transcatheter AVR at the time of LVAD implantation. Transthoracic echocardiography results showed severe aortic prosthetic valve deterioration with moderate aortic regurgitation as well as severe left ventricular dysfunction (ejection fraction, 11%). After redosternotomy, we performed transcatheter AVR via the ascending aorta and subsequent LVAD implantation. The postoperative course was uneventful. Generally, patients with structural deterioration of a bioprosthetic valve who report for LVAD therapy present considerable challenges to the surgeon. Concomitant transcatheter AVR offers a less-invasive alternative to surgical AVR that minimizes ischemic injury to myocardium.