Commentary:
An Achilles heel of LVAD support is the progressive development of de
novo aortic insufficiency. With rapidly improving technology, increased
numbers of patients’ worldwide suffering from heart failure, and a
relatively stable number of donors, we will continue to see and manage
patients who are living longer due to the advent of durable mechanical
support.
Although, with new technology comes new complications. The compelling
case report “Transcatheter aortic valve replacement in left ventricular
assist device patient – Overcoming the complications with transapical
approach and circulatory arrest” by Bjelic and colleagues from the
University of Rochester highlights this clearly. The authors describe a
patient who has lived with an LVAD for five years as a bridge to
transplant. While waiting, he developed severe aortic insufficiency. The
patient, deemed a high risk surgical candidate, initially was treated
with an attempt at percutaneous closure with an Amplatzer occluder which
failed, and unfortunately worsened his hemodynamics leading to
cardiogenic shock. Recognizing the challenging situation this places the
patient in from the standpoint of escalating mechanical circulatory
support options, the decision was then made to attempt off-label
utilization of TAVR. TAVR was attempted, with subsequent PVL, leading to
valve dislodgement into a stationary, sub-mitral position. An additional
TAVR valve was then deployed with moderate PVL but a reasonable result.
Unfortunately, in the overnight hours, the “stationary” TAVR valve
dislodged, completely occluding the LVAD inflow cannula leading to
profound hemodynamic collapse. VA-ECMO was initiated and the patient
brought to the OR. Cardiopulmonary bypass was established, and the
inflow cannula was surgically approached through a left anterior
thoracotomy. The LV inflow cannula was removed from the apex and the
migrated TAVR was subsequently removed through the apical cuff. Due to
moderate PVL of the implanted TAVR, a valve-in-valve TAVR was deployed
through the apical cuff in antegrade fashion with resolution of PVL. The
patient was weaned and decannulated from VA-ECMO the following day,
ultimately discharging to home in good condition. Most certainly, the
authors should be commended for a great save.
This is an extraordinary case which highlights a number of different and
important topics. The first being the challenge we face in the setting
of the “high surgical risk patient” who subsequently undergoes
application of an off-label new(ish) technology. These situations, while
on one-hand should be applauded for pushing the envelope and moving the
field forward, present unique challenges should an unusual complication
such as what is reported here occurs. Now, in the best of situations,
what was once a “high risk” surgical patient is now nearly
“prohibitively high risk” while in cardiogenic shock maintained on
VA-ECMO, requiring an operation for a problem not typically described in
the literature. While the result of this patient was a life saved, the
outcome may be different for others. How do we as a specialty weigh
these risks and benefits? In addition, this patient had the LVAD placed
as a bridge to transplant. Instead of placing the patient in a
potentially harmful situation with the use of various percutaneous
technologies to remedy his aortic insufficiency, could his UNOS Status
have been adjusted so the likelihood of him receiving a transplant be
expedited? These questions are the core and crux of the heart team
approach to these complicated cases.
Next, the importance of the cardiac surgeon remaining involved, engaged,
and able to perform the technical aspects of deploying percutaneous
technology cannot be discounted. As the landscape continues to change
with interventional cardiologists expanding their reach in structural
heart disease, we as surgeons must remain vigilant in remaining valuable
members of this team. This is critically important as we move forward in
order to manage unanticipated complications which result in the need for
emergency surgery, as well as the necessity to be able to employ the
technology in off hour, off label situations as described in this case
as a life-saving maneuver.
Finally, this case clearly illustrates the skill and forward thinking
nature of the surgical team at University of Rochester. From the use of
percutaneous devices, to a non-sternotomy approach and subsequent
retrieval and deployment of TAVR through the apical cuff, the management
of this patient highlights truly how far we as a specialty have evolved
in the field of durable mechanical circulatory support and heart failure
management.
With new technology comes new and more challenging surgical
complications. As surgeons we must continue to be an integral part of
the team; innovating and pivoting as new situations arise.