Transcatheter Aortic Valve Implantation Strategies and Outcomes in Pure Native Aortic Regurgitation with Left Ventricular Assist Device: An Evidence Update

Background: Aortic regurgitation (AR) is a common complication in patients following left ventricular assist device (LVAD) implantation. For these high surgical risk patients, transcatheter aortic valve implantation (TAVI) has emerged as an alternative to surgical aortic valve replacement. The unique challenges in LVAD patients, such as non-calcified device landing zones (DLZ) and dilated annuli, introduce risks for device migration, and trans-stent and paravalvular leakage (PVL), contributing to missing device success and the need for second transcatheter heart valve (THV) as valve-in-valve implantation. This research assesses procedural outcomes and survival in LVAD patients undergoing TAVI, focusing on strategies to improve device success.

Methods: From January 2017 to September 2024, 36 LVAD patients with clinically significant pure AR underwent TAVI. The primary endpoints were procedural success without need for second THV and the absence of significant postprocedural AR/PVL. Secondary outcomes included survival rates and adverse events.

Results: In the cohort, 7 patients (19.5%) received an AR-dedicated TAVI device (23 mm: 1/7 [14.2%]; 25 mm: 4/7 [57.1%]; 27 mm: 2/7 [28.6%]), with none requiring a second THV. No intraprocedural AR was observed, and only 1 patient (14.2%) had AR greater than “trace” at discharge. Additionally, 8/36 patients (22.2%) underwent DLZ pre-stenting and a standard TAVI (30 mm stent + 29 mm balloon-expandable THV: 4/8 [50%]; 23 mm stent + 29 mm balloon-expandable THV: ⅜ [37.5%]; 34 mm stent + 29 mm balloon expandable THV: ⅛ [12.5%]), all without needing a second valve and no AR >“trace” during or after the procedure. In the standard TAVI group with 21/36 (58.3%) patients (27 mm mechanically expandable THV: 1/21 [4.8%]; 27 mm top-down self-expandable THV: 10/21 [47.6%]; 29 mm balloon-expandable valve: 9/21 [42.9%]; 30.5 mm balloon-expandable THV: 1/21 [4.8%]), 33.3% required a second THV, with intraprocedural AR >“trace” in 14.3%, which dropped to 4.8% by discharge. No patient had moderate or severe AR at discharge. In-hospital mortality was 5.5%, with median follow-up survival of 294 days (IQR 89–841 days).

Conclusion: TAVI demonstrates promising procedural outcomes and early survival in LVAD patients with AR. Dedicated devices and DLZ pre-stenting improve procedural success. Further research is required to enhance outcomes in this challenging cohort, with emphasis on reducing complications and improving long-term survival.

NB: This abstract was presented in a similar form at a previous meeting.

Publication History

Article published online:
11 February 2025