Transcatheter Aortic Valve Replacement in Left Ventricular Assist Device Patients with Aortic Regurgitation

Background: Development of aortic regurgitation (AR) following left ventricular assist device (LVAD) implantation is common, and it is associated with a poor prognosis. Transcatheter aortic valve replacement (TAVR) has become a mainstay therapy for patients with severe aortic stenosis, with an off-label use for severe AR. The aim of this study was to assess the feasibility and durability of TAVR in LVAD patients with significant AR. Methods: We evaluated all LVAD patients within our database that underwent TAVR for AR. Clinical and echocardiographic data were collected before and after TAVR procedure. Aortic regurgitant fraction (RF) was calculated using outflow graft Doppler echocardiography. Results: Seven patients underwent nine attempted TAVR procedures. Median age was 69 (IQR 63–73) and 43% were female. Median time from LVAD to TAVR was 23 (IQR 17–52) months. One procedure was aborted due to vascular complications, and one patient underwent two separate procedures 22 months apart. Five patients (71%) survived over median follow-up of 9 (IQR 6–23) months. Two patients died of paravalvular complications following device deployment. Procedural success was achieved in 67% of attempts, with significant improvement in RF from 44.8% (IQR 37.6–63.6) pre-procedurally to 28.1% (IQR 0.30–29.6) at six-month follow-up. Qualitatively, mild or moderate paravalvular leak was noted on all surviving patients at one- and six-month follow-up. There was significant improvement in right ventricular function at 6-month follow-up. Conclusion: TAVR is a reasonable option for treating LVAD-induced AR. Longer follow-up and larger cohorts are needed to assess the durability and long-term efficacy of this procedure. Abbreviations: AR: Aortic regurgitation; AV: Aortic valve; LV: Left ventricle; LVAD: Left ventricular assist device; LVIDd: Left ventricular internal dimension at end-diastole; LVIDs: Left ventricular internal dimension at end-systole; PAPi: Pulmonary artery pulsatility index; RA: Right atrial; RF: Regurgitant fraction; RV: Right ventricle; RVEDA: Right ventricular end-diastolic area; RVFAC: Right ventricular fractional area change; RVSP: Right ventricular systolic pressure; TAPSE: tricuspid annular plane systolic excursion; TAVR: Transcatheter aortic valve replacement; TV: Tricuspid valve