Aortic valve regurgitation or injury
Iatrogenic injury of the aortic valve (AV) is a potential complication
related to the Impella resulting in significant aortic valve
regurgitation (AR) (Figure 1). There are various contributing factors
that can be considered that may lead to AR (Table 1.). Recent studies
have described several mechanisms that can cause injury of the AV during
the implantation, repositioning, and removal of the Impella device
[14-16]. The aortic valve might be damaged by the stiff guidewire
during the insertion or with the Impella device itself following the
guidewire going through the leaflet. Alternatively, improper handling of
the device such as insertion across the aortic valve without the
guidewire or without echocardiographic guidance might be one of the
mechanisms. In addition, direct contact of the inlet during
repositioning or removal of the Impella might damage the valve due to
the effect of suction if the flow is not reduced as per guidelines.
Severe AR caused by aortic valve injury may necessitate further
treatment such as aortic valve replacement or transcatheter aortic valve
intervention. It is important to distinguish AR caused by commissural
malcoaptation of the two leaflets related to the device, which might
improve after its removal [17]. AR can be challenging to detect with
echocardiography because of the artefacts generated by the device
[15]. Importantly, a recent observational study has demonstrated
that even after short-term Impella support, a significant proportion of
patients may develop progression of AR [18]. The authors have
observed this complication in 9 patients despite an extremely short
support duration in their cohort (median less than 1 day) [18].
However, the causality of AR and follow-up of these patients were not
investigated.