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.