Aortic Insufficiency: How Often Does It Occur and When To Treat

Transcription

1 Aortic Insufficiency: How Often Does It Occur and When To Treat Simon Maltais, MD PhD Vice-Chair of Clinical Practice Director of MCS Program Department of Cardiovascular Surgery Mayo Clinic, Rochester, MN AATS MCS 2018, Houston (TX)

2 Disclosures Relevant financial relationship(s) with industry: Paid consultant for Medtronic, Abbott, and Clearflow Inc. I do NOT intend to discuss offlabel/investigative uses(s) of commercial product(s)/devices(s) during this presentation

3 Case Presentation 61 year old man with ischemic cardiomyopathy. Reversible pulmonary hypertension, renal insufficiency and severe peripheral vascular disease (previous aortobifemoral graft). Offered MCS as destination therapy with HMII.

4 Intraoperative Echo

5 Intraoperative Echo

6 Case Presentation Uneventful HeartMate 2 Implant Weaned from Cardiopulmonary bypass with 8800rpm, PI 5.6, flow >5L/min Progressive hypotension and RV failure 10 minutes after weaning from CPB

7 Intraoperative Echo

8 Intraoperative Echo

9 What to DO? 1. Manage conservatively with speed manipulation 2. Perform aortic valve repair (Park Stich) 3. Perform bioprosthetic AVR 4. Close the aortic valve

10 Case Presentation CPB resumed and LVAD turned off. Outflow graft disconnected from pump housing (still sewn to aorta) Proximal aortotomy to visualize bicuspid aortic valve with R-L fusion pattern Aortic valve closed weaned successfully with 8800 rpm, PI 4.6, LVAD flow >4.5L/min Doing well in follow-up 3 years post LVAD implant with fused aortic valve

11 TTE (3 years)

12 AI in LVAD patients Cowger JA et al. JHLT 2015.

13 AI and LVAD Efficiency AI creates a redundant, closed loop which lowers LVAD efficiency LV LVAD Ascending Aorta Retrograde across the aortic valve LV Increasing LVAD speeds and power are then needed to maintain adequate systemic flow

14 Clinical Relevance of AI in LVAD 1. Redundant loops reduces forward flow and organ perfusion 2. Increased regurgitant volume can lead to recurrent signs of heart failure and congestion 3. Pump speeds can be increased to overcome the AI but this can often leads to hemolysis, worsening acquired VWD, bleeding and worsening AI over time 4. Definitive management includes: Surgical aortic valve replacement, repair, or closure Percutaneous closure with an amplatzer device,tavr, mitral clip Transplant Unfortunately, there have been conflicting reports of the clinical significance of AI Jorde UP / Uriel N / Naka Y et al. Circ Heart Fail 2014;7: Cowger JA / Aaronson KD et al. JHLT 2014;33:

15 Prevalence and Incidence of AI 1 in 4 patients will develop de novo at least mild to moderate AI within 1 year after LVAD AI in CF-LVAD patients tends to be progressive Jorde UP / Uriel N / Naka Y et al. Circ Heart Fail 2014;7: Cowger JA / Aaronson KD et al. JHLT 2014;33:

16 High Speed and Progressive AI High CF-LVAD Speeds Increased Pressure in Aorta Decreased Pressure in LV Closed AoV Commissural fusion of leaflet tissue 1 Deterioration of leaflet tissue 1 Aortic Insufficiency 2,3, 4 Clinically significant aortic insufficiency may progress 3,4 1. Mudd et al. J Heart Lung Transplant (12) 2. Pak et al. J Heart and Lung Transplant (10) 3. Aggarwal et al. Ann Thorac Surg (2) 4. Cowger et al. Circ HF (6)

17 Predictors of Worsening AI

18 Aortic Valve Opening and AI Jorde UP / Uriel N / Naka Y et al. Circ Heart Fail 2014;7:310-9.

19 AI at implant Treat anything greater than mild

20 Aortic Concomitant Procedures Outcomes Robertson JO et al. JHLT 2015.

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23 Novel Therapeutic Options 2011 MFMER

24 What to DO? Bioprosthetic valves (and TAVI) have a high propensity for fusion and early failure in patients supported by CF- VAD (Bonios et al, ASAIO J 2016) Aortic valve repair is our preferred method of surgical management and when not feasible, complete closure of the LVOT Choice of the procedure should be guided with: transplant eligibility, risk reoperation, percutaneous candidacy

25 Let s POLL it! Given the available data, my preferred management of AI is: 1. Manage conservatively 2. Perform aortic valve repair 3. Perform bioprosthetic AVR 4. Complete aortic valve closure

26 Thank you! 2011 MFMER