Percutaneous transcatheter closure of the aortic valve to treat cardiogenic shock in a left ventricular assist device patient with severe aortic insufficiency

In this case report, we present a patient status post left ventricular assist device implantation complicated by de novo aortic insufficiency. At 8 months postimplant, the patient underwent a reoperative aortic valve repair, without complete closure of the valve. Three months after reoperation, the patient developed cardiogenic shock secondary to recurrent, severe aortic insufficiency. Ultimately, the patient underwent percutaneous, transcatheter closure of the aortic valve with an Amplatzer Cribiform device (AGA Medical Corp, Plymouth, MN). Two months post procedure, the patient remains stable with improved symptoms and functional status, and without evidence of further aortic insufficiency or device migration.     

Native aortic valve insufficiency in patients with left ventricular assist devices

Management of mild to moderate aortic insufficiency in patients with a left ventricular assist device remains controversial. We report 3 patients with aortic insufficiency and pulsatile left ventricular assist devices treated with a central aortic valve coapting suture. Two of the repairs have been durable for more than 1 year and aspirin appears to be sufficient anticoagulation.     

Late aortic dissection in a patient with a left ventricular assist device

The limited availability of donor hearts means that an increasing number of transplantation candidates are temporarily or permanently supported by mechanical circulatory assist devices. We report a patient undergoing implantation of a Novacor left ventricular assist device who suffered fatal aortic dissection on postoperative day 11 after satisfactory recovery from multiple organ failure. The dissection of the aorta initially presented as an embolic peripheral ischemia. Early complete echocardiography is thus warranted to rule out dissection.     

Late aortic dissection in a patient with a left ventricular assist device.

The limited availability of donor hearts means that an increasing number of transplantation candidates are temporarily or permanently supported by mechanical circulatory assist devices. We report a patient undergoing implantation of a Novacor left ventricular assist device who suffered fatal aortic dissection on postoperative day 11 after satisfactory recovery from multiple organ failure. The dissection of the aorta initially presented as an embolic peripheral ischemia. Early complete echocardiography is thus warranted to rule out dissection.     

Partial aortic valve fusion induced by left ventricular assist device

BACKGROUND: Left ventricular assist devices (LVADs) may be used (1) as a bridging device to cardiac transplantation, (2) for permanent replacement of left ventricular function, and (3) as a bridge to recovery of ventricular function, for example, in recoverable myocardial disease. In this third group of patients, it is important that the LVAD does not produce changes in the heart that will have a deleterious effect on cardiac function once the device is removed. Furthermore, if the LVAD fails, survival depends on optimal function of the diseased heart. METHODS: All hearts with LVADs encountered as surgical specimens following heart transplantation or at autopsy at the Fairview-University of Minnesota Medical Center during the 5-month period August 1998 to January 1999 were examined for native valvular heart disease. The nature and extent of commissural fusion was noted and measured. Light microscopy was performed on any valve lesions. RESULTS: Four of 6 patients with HeartMate (Thermo Cardiosystems, Inc, Woburn, MA) LVADs showed evidence of commissural fusion (acquired aortic stenosis). In 1 patient, this condition was caused by an organizing thrombus uniting a 14-mm length of the commissural region of the right coronary and noncoronary cusps of the aortic valve. Fibrous commissural fusion due to totally organized thrombus in the other 3 patients affected one aortic commissure (2 patients, 2 mm and 4 mm, respectively) and two commissures (1 patient, 2 mm and 5 mm). Partial cuspal fusion in each case was due to permanent closure of the native aortic valve induced by the LVAD's operating in its automatic setting. Mean length of commissural fusion was 5.4 mm (range, 2 to 14 mm; standard deviation [SDI = +/-5.0 mm). Mean duration of implantation of the six LVADs was 180.3 days (range, 26 to 689 days; SD = +/-253.8 days). The LVADs of the 3 patients with fibrous fusion of the commissures had been implanted for an average of 252.3 days (range, 26 to 689 days; SD = +/-378.2 days). CONCLUSIONS: Normal function of the LVAD produces permanent closure of the native aortic valve. Stasis on the ventricular aspect of the aortic valve, combined with a low level of anticoagulation, favors thrombosis at this site. Thrombus organization leads to aortic stenosis of variable severity. This previously unsuspected complication was not detected clinically in any of our patients. Aortic stenosis may hold serious implications for patients in whom the LVAD acts as a bridge to recovery or in those in whom the LVAD fails. Prevention may be achieved by intermittently reducing LVAD pumping action. A built-in venting cycle would be of value in long-term implants. Thrombi on the aortic valve may also predispose patients to infective endocarditis, because bloodstream infection is common in patients with LVADs.     

单纯主动脉瓣关闭不全超大瓣环患者的支架加宽和人工腱索辅助下TAVI技术

非钙化单纯主动脉瓣关闭不全(noncalcified pure aortic insufficiency,NPAI)是老龄化社会中退行性心脏瓣膜病的常见类型之一。大多数NAPI患者可见其主动脉瓣环明显扩大且其病变主动脉瓣缺少钙化灶支撑,故对于这类患者难以常规行经导管主动脉瓣置入术(transcatheter aorti...     

Laparoscopic cholecystectomy in a patient with an implantable left ventricular assist device

Left ventricular assist devices (LVADs) provide mechanical supportfor left ventricular ejection in the failing heart. We describethe anaesthetic management of a patient with an LVAD requiringlaparoscopic cholecystectomy. A 51-yr-old female patient withsevere heart disease had a Heartmate II LVAD implanted 4 monthsbefore this proposed elective surgery. Maintaining haemodynamicstability in the perioperative period is essential in such patients.The case was managed successfully using invasive monitoringand anaesthesia with sevoflurane and remifentanil. The potentialproblems in management of patients with LVADs are highlightedand discussed. A team approach is essential.     

Lung lobectomy in a patient with an implantable left ventricular assist device

Non-cardiac surgical procedures in patients with left ventricular assist devices (LVADs) pose a special challenge given the hemodynamic and hematologic considerations in these patients. During pulmonary procedures in patients with LVADs, special attention should be paid to hemodynamics because lung resection surgery requires a lateral decubitus position, single-lung ventilation and postoperative decrease in the pulmonary vascular bed, all of which may lead to inadequate preload to the LVAD. We present a case of lower lobectomy of the left lung for an adenocarcinoma found in a patient with an implantable continuous-flow LVAD.