Natural history and clinical effect of aortic valve regurgitation after left ventricular assist device implantation

ObjectivesAortic valve regurgitation reduces left ventricular assist device mechanical efficiency. Evidence has also suggested that left ventricular assist device implantation can induce or exacerbate aortic valve regurgitation. However, this has not been compared with aortic valve regurgitation progression in a nonsurgical end-stage heart failure population. Furthermore, its clinical effect is unclear. We sought to characterize the development and progression of aortic valve regurgitation in left ventricular assist device recipients and to identify its clinical effect.MethodsA review of all consecutive patients who received an intracorporeal left ventricular assist device at Duke University Medical Center from January 2004 to January 2011 was conducted. Cases of previous or concomitant aortic valve surgery were excluded. Data from the remaining implants (n = 184) and a control group of contemporaneous nonsurgical patients with end-stage heart failure (n = 132) were analyzed. Serial transthoracic echocardiography was used to characterize aortic valve regurgitation as a function of time.ResultsLeft ventricular assist device implantation was associated with worsening aortic valve regurgitation, defined as an increase in aortic valve regurgitation grade, relative to the nonsurgical patients with end-stage heart failure (P < .0001). The recipients of continuous flow left ventricular assist devices were more likely than recipients of pulsatile left ventricular assist devices to develop worsening aortic valve regurgitation (P = .0348). Moderate or severe aortic valve regurgitation developed in 21 left ventricular assist device recipients; this was unrelated to the type of device implanted (continuous vs pulsatile; P = .754) or aortic valve regurgitation grade before left ventricular assist device implantation (P = .42). Five patients developed severe aortic valve regurgitation; all of whom underwent aortic valve procedures.ConclusionsNative aortic valve regurgitation developed and/or progressed after left ventricular assist device implantation, with this effect being more pronounced in continuous flow left ventricular assist device recipients. However, the preoperative aortic valve regurgitation grade failed to correlate with the development of substantial aortic valve regurgitation after left ventricular assist device implantation. After left ventricular assist device implantation, aortic valve regurgitation had a small, but discernible, clinical effect, with some patients developing severe aortic valve regurgitation and requiring aortic valve procedures. These data have implications for the long-term management of left ventricular assist device recipients, in particular as the durability of implantable continuous flow left ventricular assist device therapy improves

Anaortic, off-pump coronary artery bypass using multiple arterial grafts: Surgical technique

Traditional on-pump coronary artery bypass grafting on an arrested heart using a single arterial graft carries 2 main potential drawbacks: the risk of perioperative neurological injury and the known failure rate of vein grafts. To address this, we describe a surgical technique of anaortic, off-pump coronary artery bypass that avoids all manipulation of the ascending aorta and uses multiple-arterial grafts to achieve complete revascularisation. This provides optimal short- and long-term outcomes and is particularly important in high-risk subgroups. The standard graft configuration is the left internal mammary artery to the anterior wall, and the right internal mammary artery is extended with the radial artery and brought through the transverse sinus to revascularise the lateral and inferior walls sequentially. Alternative configurations, including “T” grafts and using long saphenous vein, are considered if patients have factors limiting arterial conduit selection. Arterial conduits are harvested using a skeletonised technique. The radial artery may also be harvested endoscopically. Wide, bilateral retrothymic tunnels are formed for the internal mammary arteries. The pericardium is opened using specific incisions designed to facilitate positioning of the heart whilst maintaining venous return and cardiac output. There are 4 main positions for the heart during grafts (high-lateral wall, low-lateral wall, inferior wall and anterior wall). These are obtained using a combination of table position, wet sponges, two nylon sutures placed in the pericardium and the off-pump stabiliser. All distal anastomoses are performed using homemade intra-coronary silastic shunts, which provide optimal grafting conditions. Graft patency is confirmed using transit-flow time measurement