From the Guidelines
Management of aortic insufficiency (AI) in patients with Left Ventricular Assist Devices (LVADs) requires a proactive approach, with the primary recommendation being to address AI early through medical therapy, device optimization, and surgical intervention when necessary, as supported by the most recent study 1.
Key Recommendations
- Medical management includes afterload reduction with ACE inhibitors or ARBs, along with diuretics to manage volume status, as mentioned in 1.
- LVAD speed optimization is crucial, with reducing pump speed potentially decreasing the pressure gradient across the aortic valve and allowing more frequent valve opening, as discussed in 1.
- For moderate to severe AI causing symptoms or hemodynamic compromise, surgical intervention should be considered, including aortic valve replacement, repair, or closure procedures during LVAD implantation or as a separate procedure, as recommended in 1.
- Regular echocardiographic monitoring every 3-6 months is essential to detect AI progression, highlighting the importance of ongoing surveillance in these patients, as emphasized in 1.
Pathophysiology and Clinical Implications
The continuous flow from the LVAD can lead to a closed aortic valve, resulting in commissural fusion and regurgitation, which can cause a futile cycle of blood recirculation between the aorta and left ventricle, reducing forward flow and potentially causing heart failure symptoms despite LVAD support, as explained in 1.
Mitigation Strategies
Strategies to mitigate AI and right-sided heart failure (RHF) include customizing the hemodynamic milieu based on specific patient characteristics, as discussed in 1.
Importance of Hemodynamic Management
The focus on the hemodynamic milieu is critical to tailor support and minimize morbidity in patients with LVADs, as highlighted in 1.