From the Guidelines
Managing aortic insufficiency (AI) in patients with Left Ventricular Assist Device (LVAD) support requires a multifaceted approach based on the severity of regurgitation and patient symptoms. For mild to moderate AI, close monitoring with regular echocardiographic assessment every 3-6 months is recommended, as AI tends to progress over time with LVAD support 1. Medical management should include afterload reduction with ACE inhibitors (such as lisinopril 10-40 mg daily or enalapril 5-40 mg daily) or angiotensin receptor blockers (such as losartan 25-100 mg daily), which can reduce the regurgitant volume 1. Diuretics like furosemide (20-80 mg daily) may help manage volume overload symptoms. Some key points to consider in the management of AI in LVAD patients include:
- More than mild AI should be corrected at the time of LVAD implantation 1
- Post-operatively, serial echocardiographic monitoring for regular AV opening mitigates development of de novo AI or worsening of existing AI 1
- Optimizing cardiovascular hemodynamics can further reduce risk: preload reduction by volume status adjustment, AV opening and ejection by speed optimization, and afterload reduction by systemic blood pressure control 1
- Hypertension increases afterload and the transvalvular pressure differential, thus resulting in reduced AV opening with a greater likelihood of valve leaflet fusion and subsequent development of AI 1 For severe AI causing symptoms or hemodynamic compromise, surgical intervention should be considered, with options including transcatheter aortic valve replacement (TAVR), surgical aortic valve replacement, or aortic valve closure/patch 1. In some cases, adjusting LVAD parameters by reducing pump speed may decrease the pressure gradient across the aortic valve and reduce regurgitation, though this must be balanced against maintaining adequate systemic perfusion 1. The development of AI after LVAD implantation occurs due to the continuous unloading of the left ventricle, which reduces aortic valve opening and leads to commissural fusion and valve degeneration over time 1. Regular aortic valve opening, achieved through intermittent reduction in LVAD speed under careful monitoring, may help prevent progression of AI in selected patients 1. Technologic advancements, such as alternative flow algorithms that promote aortic valve opening, may also play a role in mitigating AI in LVAD patients 1.