Vriz Olga, Mushtaq Ali, Shaik Abdullah, El-Shaer Ahmed, Feras Khalid, Eltayeb Abdalla, Alsergnai Hani, Kholaif Naji, Al Hussein Mosaad, Albert-Brotons Dimpna, Simon Andre Rudiger, Tsai Felix Wang
Heart Centre Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.
School of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
Front Cardiovasc Med. 2023 Jan 9;9:1094796. doi: 10.3389/fcvm.2022.1094796. eCollection 2022.
Patients suffering from end-stage heart failure tend to have high mortality rates. With growing numbers of patients progressing into severe heart failure, the shortage of available donors is a growing concern, with less than 10% of patients undergoing cardiac transplantation (CTx). Fortunately, the use of left ventricular assist devices (LVADs), a variant of mechanical circulatory support has been on the rise in recent years. The expansion of LVADs has led them to be incorporated into a variety of clinical settings, based on the goals of therapy for patients ailing from heart failure. However, with an increase in the use of LVADs, there are a host of complications that arise with it. One such complication is the development and progression of aortic regurgitation (AR) which is noted to adversely influence patient outcomes and compromise pump benefits leading to increased morbidity and mortality. The underlying mechanisms are likely multifactorial and involve the aortic root-aortic valve (AV) complex, as well as the LVAD device, patient, and other factors, all of them alter the physiological mechanics of the heart resulting in AV dysfunction. Thus, it is imperative to screen patients before LVAD implantation for AR, as moderate or greater AR requires a concurrent intervention at the time of LVADs implantation. No current strict guidelines were identified in the literature search on how to actively manage and limit the development and/or progression of AR, due to the limited information. However, some recommendations include medical management by targeting fluid overload and arterial blood pressure, along with adjusting the settings of the LVADs device itself. Surgical interventions are to be considered depending on patient factors, goals of care, and the underlying pathology. These interventions include the closure of the AV, replacement of the valve, and percutaneous approach percutaneous occluding device or transcatheter aortic valve implantation. In the present review, we describe the interaction between AV and LVAD placement, in terms of patient management and prognosis. Also it is provided a comprehensive echocardiographic strategy for the precise assessment of AV regurgitation severity.
患有终末期心力衰竭的患者往往死亡率很高。随着越来越多的患者病情发展为严重心力衰竭，可用供体的短缺日益受到关注，接受心脏移植（CTx）的患者不到10%。幸运的是，近年来，作为机械循环支持变体的左心室辅助装置（LVADs）的使用呈上升趋势。LVADs的扩展使其基于心力衰竭患者的治疗目标被纳入各种临床环境。然而，随着LVADs使用的增加，随之出现了一系列并发症。其中一种并发症是主动脉瓣反流（AR）的发生和进展，这被认为会对患者的预后产生不利影响，并损害泵的益处，导致发病率和死亡率增加。其潜在机制可能是多因素的，涉及主动脉根部-主动脉瓣（AV）复合体，以及LVAD装置、患者和其他因素，所有这些都会改变心脏的生理力学，导致AV功能障碍。因此，在LVAD植入前对患者进行AR筛查至关重要，因为中度或更严重的AR需要在LVAD植入时同时进行干预。由于信息有限，在文献检索中未发现关于如何积极管理和限制AR发生和/或进展的现行严格指南。然而，一些建议包括通过针对液体超负荷和动脉血压进行药物管理，以及调整LVAD装置本身的设置。应根据患者因素、护理目标和潜在病理情况考虑手术干预。这些干预措施包括关闭AV、更换瓣膜以及经皮方法——经皮封堵装置或经导管主动脉瓣植入。在本综述中，我们描述了AV与LVAD放置之间在患者管理和预后方面的相互作用。此外，还提供了一种全面的超声心动图策略，用于精确评估AV反流的严重程度。
