Ando Masahiko, Ono Minoru
Department of Cardiac Surgery, The University of Tokyo Hospital, Tokyo, Japan.
Front Cardiovasc Med. 2022 Nov 15;9:1029984. doi: 10.3389/fcvm.2022.1029984. eCollection 2022.
Moderate to severe aortic insufficiency (AI) in patients who underwent continuous-flow left ventricular assist device (CF-LVAD) implantation is a significant complication. According to the INTERMACS registry analysis, at least mild AI occurs in 55% of patients at 6 months after CF-LVAD implantation and moderate to severe AI is significantly associated with higher rates of re-hospitalization and mortality. The clinical implications of these data may underscore consideration of prophylactic aortic valve replacement, or repair, at the time of CF-LVAD implantation, particularly with expected longer duration of support and in patients with preexisting AI that is more than mild. More crucially, even if a native aortic valve is seemingly competent at the time of VAD implantation, we frequently find AI as time goes by, potentially due to commissural fusion in the setting of inconsistent aortic valve opening or persistent valve closure caused by CF-LVAD support, that alters morphological and functional properties of innately competent aortic valves. Therefore, close monitoring of AI is mandatory, as the prognostic nature of its longitudinal progression is still unclear. Clearly, significant AI during VAD support warrants surgical intervention at the appropriate timing, especially in patients of destination therapy. Nonetheless, such an uncertainty in the progression of AI translates to a lack of consensus regarding the management of this untoward complication. In practice, proposed surgical options are aortic valve replacement, repair, closure, and more recently transcatheter aortic valve implantation or closure. Transcatheter approach is of course less invasive, however, its efficacy in terms of long-term outcome is limited. In this review, we summarize the recent evidence related to the pathophysiology and surgical treatment of AI associated with CF-LVAD implantation.
接受持续血流左心室辅助装置（CF-LVAD）植入的患者出现中重度主动脉瓣关闭不全（AI）是一种严重并发症。根据INTERMACS注册研究分析，至少轻度AI在CF-LVAD植入后6个月时出现在55%的患者中，中重度AI与再住院率和死亡率的升高显著相关。这些数据的临床意义可能强调在CF-LVAD植入时考虑预防性主动脉瓣置换或修复，特别是在预期支持时间较长以及存在中度以上AI的患者中。更关键的是，即使在VAD植入时天然主动脉瓣看似功能正常，但随着时间推移我们经常发现AI，这可能是由于CF-LVAD支持导致主动脉瓣开放不一致或持续关闭的情况下瓣叶融合，从而改变了原本功能正常的主动脉瓣的形态和功能特性。因此，对AI进行密切监测是必不可少的，因为其纵向进展的预后性质仍不清楚。显然，VAD支持期间出现显著AI需要在适当的时候进行手术干预，特别是在接受目标治疗的患者中。然而，AI进展的这种不确定性导致对于这种不良并发症的管理缺乏共识。在实践中，提出的手术选择包括主动脉瓣置换、修复、关闭，以及最近的经导管主动脉瓣植入或关闭。经导管方法当然侵入性较小，然而，其长期疗效有限。在本综述中，我们总结了与CF-LVAD植入相关的AI的病理生理学和外科治疗的最新证据。
