Percutaneous transcatheter closure of the aortic valve to treat aortic insufficiency after LVAD implantation

We present a patient with progressive aortic regurgitation that developed following successful implantation of a left ventricular assist device (LVAD). We were able to correct this known complication of LVAD by occluding the aortic valve percutaneously with an Amplatzer^TM multi-fenestrated septal occluder – Cribriform. This is the first such case to be reported in the UK.

Mattar - Figure 1. Two-dimensional (2D) transoesophageal echocardiography (TOE) long-axis colour Doppler across the aortic valve showing the extent and severity of aortic regurgitation (AR) — Figure 1. Two-dimensional (2D) transoesophageal echocardiography (TOE) long-axis colour Doppler across the aortic valve showing the extent and severity of aortic regurgitation (AR)

Case

A 59-year-old male patient was referred to our hospital for further management of end-stage heart failure and transplant assessment secondary to atypical cardiomyopathy (arrhythmogenic right ventricular cardiomyopathy [ARVC] with left ventricular [LV] involvement).

Mattar - Figure 2. 2D TOE long-axis colour Doppler across the aortic valve showing the extent and severity of AR — Figure 2. 2D TOE long-axis colour Doppler across the aortic valve showing the extent and severity of AR

Following the multi-disciplinary selection process and accompanying investigations, a Heartware^TM LVAD (Heartware, Massachusetts, USA) was implanted. Routine follow-up included regular transthoracic echocardiograms (TTE). Over the next two years the aortic regurgitation progressed from mild to severe. The patient’s heart failure symptoms deteriorated and, despite being admitted for optimisation of his heart failure treatment, it was evident that medical management was insufficient. His case was discussed at the multi-disciplinary team (MDT) meeting and further options for treatment of his aortic regurgitation (AR) were explored. Aortic valve replacement was considered to be too high risk (EuroSCORE II 61.58%) and transcatheter aortic valve implantation (TAVI) was deemed not feasible due to the absence of calcification on the aortic valve.

Mattar - Figure 3. 2D TOE long-axis view of the aortic valve showing the deployment of the left ventricular (LV) disc — Figure 3. 2D TOE long-axis view of the aortic valve showing the deployment of the left ventricular (LV) disc

It was decided to occlude the aortic valve percutaneously using a patent foramen ovale (PFO) occluder. As the LVAD was implanted as a bridge to transplant, the aortic valve was redundant, as it was not opening with the LVAD in place. This particular occluder device was selected as both discs are equal in size and they are connected with a fine spindle, thus, permitting central positioning of the discs in the orifice of the regurgitant, native aortic valve.

Mattar - Figure 4. A fluoroscopic image showing the release of the LV disc — Figure 4. A fluoroscopic image showing the release of the LV disc

Mattar - Figure 5. 2D TOE long-axis view of the aortic valve showing exposure of both LV and aortic discs across the aortic valve — Figure 5. 2D TOE long-axis view of the aortic valve showing exposure of both LV and aortic discs across the aortic valve

The procedure was performed under general anaesthesia. The patient was taking warfarin and his international normalised ratio (INR) was 2.8 on the day of the procedure, so additional anticoagulation was not needed peri-operatively. Transoesophageal echocardiography (TOE) was used to measure and assess the aortic valve annulus (figures 1 and 2). An 8Fr sheath was introduced percutaneously into the right femoral artery. The aortic valve was crossed with a pigtail catheter, which was then exchanged for an Amplatz Super Stiff^TM wire (Boston Scientific, Massachusetts, USA). A 25 mm Amplatzer^TM multi-fenestrated septal Cribriform^TM occluder (St. Jude Medical, Minnesota, USA) was loaded onto the delivery system. The LV disc was deployed and the device was then retracted back against the aortic valve (figures 3 and 4). The second disc was released subsequently on the aortic side of the valve (figures 5 and 6). The device was gently rocked back and forth while still attached to the delivery system to confirm stable positioning. Then the septal occluder was released from the delivery system into position spanning the aortic valve.

Mattar - Figure 6. A fluoroscopic image showing exposure of both discs before releasing the occluder from the delivery system — Figure 6. A fluoroscopic image showing exposure of both discs before releasing the occluder from the delivery system

Concurrent intra-operative TOE imaging showed the occluder device to be positioned satisfactorily with immediate reduction of AR on colour Doppler (figures 7 and 8). An aortogram confirmed normal blood flow in the coronary arteries (figure 9). The patient emerged from general anaesthesia without problem and made an uneventful post-operative recovery.

Post-procedure TTE showed the occluder device seated well in a stable position and no aortic regurgitation was present. The patient was discharged home after three days.

Mattar - Figure 7. Three-dimensional (3D) TOE showing proper positioning of the closure device — Figure 7. Three-dimensional (3D) TOE showing proper positioning of the closure device

Discussion

Aortic valve insufficiency is not an uncommon complication in patients with a LVAD. It has been observed in up to 15% of patients and tends to deteriorate with the duration of LVAD support. The most likely aetiology for the development and progression of AR relates to the changes in aortic blood flow dynamics following LVAD insertion. The aortic outflow conduit is smaller than the native aorta so the blood velocities needed to maintain the device flows are greater than those normally present in the human aorta. The sheer stress and high diastolic luminal pressures lead to changes within the aortic wall and may play a role in AR seen post-implantation. In addition, alterations in blood flow dynamics and aortic pressure are likely to contribute directly to the development of aortic valve pathology. The presence of a LVAD causes intermittent opening of the aortic valve and may promote valve thickening independently, causing reduced valve pliability and cusp fusion with subsequent degeneration.¹ Significant AR leads to reduced, and then insufficient, LVAD output due to recirculation of blood via the incompetent aortic valve. This reduces the total cardiac output and diminishes end organ perfusion.^1,2

Mattar - Figure 8. 2D TOE long-axis view showing immediate reduction of AR on colour Doppler — Figure 8. 2D TOE long-axis view showing immediate reduction of AR on colour Doppler

Invariably, medical management is only effective for a short time, and other therapies for AR in LVAD patients include aortic valve replacement, patch closure of the left ventricular outflow tract (LVOT) or a single, central coating suture into the valve.³ However, such patients are extremely high risk for repeat sternotomy following previous LVAD implantation. Hence, a percutaneous therapy may have significant benefits and reduce risk to achieve such an end point.

Worldwide, there have been three cases reported of percutaneous aortic valve occlusion with a septal occluder,^4-6 in addition to a case series of five patients.⁷ There have been no similar cases reported in the UK.

Mattar - Figure 9. An aortogram showing proper positioning of the closure device and patency of the coronary arteries — Figure 9. An aortogram showing proper positioning of the closure device and patency of the coronary arteries

Conclusion

Increasing use of LVADs will result in a concomitant rise in the incidence of AR in this unusual population of patients. We report a case in such a patient where percutaneous occlusion of the aortic valve with an Amplatzer^TM multi-fenestrated septal occluder, Cribriform, proved feasible and successful. We suggest this treatment may be considered for patients in whom repeat sternotomy represents a higher or worse risk.

Conflict of interest

None declared.

References

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7. Parikh KS, Mehrotra AK, Russo MJ et al. Percutaneous transcatheter aortic valve closure successfully treats left ventricular assist device-associated aortic insufficiency and improves cardiac hemodynamics. JACC Cardiovasc Interv 2013;6:84–9. https://doi.org/10.1016/j.jcin.2012.08.021