Surgical closure of left ventricular outflow tract after left ventricular assist device implantation in patients with aortic valve pathology

Background: In patients with refractory heart failure, aortic valve (AV) insufficiency or the presence of a prosthetic AV has been considered a relative contraindication to left ventricular assist device (LVAD) therapy. Nevertheless, we have successfully implanted LVADs in 5 patients with native AV insufficiency or an AV prosthesis by closing the left ventricular outflow tract (LVOT).

Methods: The method of LVOT closure was tailored to the patients' differing circumstances. Patient 1 had a regurgitant tri-leaflet native AV. Patient 2 had undergone previous aortic root reconstruction with a porcine bioprosthesis. Patient 3 had a congenitally bicuspid AV with significant insufficiency. Patient 4 had a native tri-leaflet valve that developed thrombus and insufficiency after previous LVAD placement. Patient 5 required removal of a recently placed mechanical AV. Accordingly, the LVOT was closed with a bovine pericardial patch in Patients 1, 4 and 5, and the lines of coaptation of the AV leaflets were closed primarily in Patients 2 and 3.

Results: Four months post-operatively, 1 patient underwent heart transplantation; on removal of the heart, LVOT patch integrity was confirmed visually. After a follow-up period of 6 months to 2 years, the remaining 4 patients are in New York Heart Association Functional Class I while awaiting cardiac transplantation. Transesophageal echocardiography has confirmed persistent LVOT closure.

Conclusion: In all 5 cases, LVOT closure circumvented the challenges associated with LVAD therapy in the presence of native AV insufficiency or an AV prosthesis.