mechanical circulatory devices: contemporary long-term
TRANSCRIPT
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Mechanical Circulatory Devices: Contemporary Long-Term Management
Do Mitral and Tricuspid Valves Need to be Repaired at Time of VAD Implant
Mark S. Slaughter, MDProfessor and Chair
Department of Cardiovascular and Thoracic SurgeryUniversity of Louisville
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Residual Valve Regurgitation in LVAD patients• Residual Valve regurgitation after stand‐alone LVAD or LVAD+valve surgery
is associated with poor survival outcomes and increased readmissions• Single center study included all types of valve surgeries including tricuspid,
mitral and aortic
Tanaka et al. Annals of Thoracic Surgery 2018
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Tricuspid Regurgitation in LAVD
• Varied incidence of tricuspid regurgitation (TR) in patient undergoing LVAD
• Studies report incidence of clinically significant i.e. moderate or greater TR between 49‐58%
• No consensus on surgical repair of TR during LVAD therapy• Incidence of RV failure in clinically significant TR has been reported
up to 75% and 12% in mild or lesser TR
Piacentino et al. Annals of Thoracic Surgery 2011; Saeed et al. JHLT 2011Potapov et al. JHLT 2008
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Yost GL et al. J Artif Organs. 2016 Mar;19(1):21‐8.
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Kalogeropoulos AP et al. J Heart Lung Transplant. 2015 Dec;34(12):1595‐603
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Tricuspid Regurgitation in LVAD patientsSystematic Review and Meta‐Analysis
• No early mortality benefit with Tricuspid surgery• Tricuspid Surgery increased cardio‐pulmonary bypass time
Dunlay et al. ASAIO Journal 2016
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Tricuspid Regurgitation in LVAD patientsSystematic Review and Meta‐Analysis
• No early mortality benefit with Tricuspid surgery• Studies have contradictory findings with some showing benefit and
others not showing benefits
Veen et al. EJCTS 2018
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Tricuspid Regurgitation in LVAD patientsSystemic Review and Meta‐analysis
• Similar risk for RV Failure, RVAD implantation No Survival Advantage with TV surgery
Veen et al. EJCTS 2018
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Tricuspid Regurgitation in LVAD patientsPresence of Atrial Fibrillation
• No early mortality Benefit• Presence of AF increased progression of tricuspid regurgitation
Anwer et al. ASAIO Journal 2017
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Mitral Regurgitation in LVAD patients• Resolution of MR across all severities with stand‐alone LVAD
Dobrovie et al. EJCTS 2017; Morgan et al. Annals of Thoracic Surgery 2017
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Mitral Regurgitation in LVAD patients• Similar Improvement of Hemodynamics and survival outcomes
irrespective MR severity
Morgan et al. Annals of Thoracic Surgery 2017
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Mitral Regurgitation in LVAD patients Systematic Review
• No additional improvement in Hemodynamics or Survival
Choi et al. Artificial Organs 2018
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Mitral Regurgitation in LVAD patients INTERMACS Data
• Similar survival outcomes with or without concomitant MV surgery in LVAD
• Increased hospital readmission without concomitant MV surgery
Robertson et al. JHLT 2018
SURVIVAL FREEDOM FROM FIRST HOSPITAL READMISSION
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Mitral Regurgitation in LVAD patients Role of Mitraclip prior to LVAD
• No additional improvement in Hemodynamics• Progression of heart failure requiring LVAD
Schmitto et al. Journal of Thoracic Disease 2018
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Valve Regurgitation in LVAD patients: Mock Loop Studies
• Isolated LVAD provided sufficient support in the setting of severe MR or TR compared with control
• Presence of BiVAD improved flows and RA pressure compared to LVAD alone in both MR and TR
• Current findings are consistent with conservative management of MR and TR in the setting of mechanical support
Shehab et al. ASAIO Journal 2018
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Regurgitation in LVAD patients
• Single center studies that demonstrate some clinical benefit• Larger patient series and meta‐analysis currently do not support routine valve repair
• Most MR can be addressed through pump management and reverse remodeling of the LV
• Most TR is a manifestation of chronic LV dysfunction and late presentation • RV dysfunction/failure is clearly associated with poor long term outcomes• Heterogeneous patient population makes it difficult to make broad surgical recommendations
• In selected patients there is probably a benefit to having no volume overloading valvular pathology