Mitral and aortic valve surgery during left ventricular assist device implantation

Central MessageEvolving evidence suggests that indications for mitral or aortic valve surgery during LVAD implantation may be expanding in select patients with mitral regurgitation or aortic insufficiency.See Commentaries on pages 978 and 979. Evolving evidence suggests that indications for mitral or aortic valve surgery during LVAD implantation may be expanding in select patients with mitral regurgitation or aortic insufficiency. See Commentaries on pages 978 and 979. Feature Editor Note—As surgeons, it is necessary to know not only how to fix a problem, but as importantly, when to fix it. Sometimes less is more; at the same time, not addressing a surgical lesion may decrease the quantity and quality of the patient's life. These decisions pervade our practice in cardiac surgery, whether on the basis of dogma, observation, or systematic research. The development of durable mechanical circulatory support represents a huge step forward in the treatment of advanced heart failure. Continued design improvements have expanded the pool of eligible patients as well as their survival. While this technology extends life, it also allows for progression of other disease processes. Heart failure surgeons face this predicament during implant: fix what is broken, let the pump fix it, fix everything every time, or never fix anything. The lack of unbiased data has made this an area of ongoing controversy. In this Invited Expert Opinion, the authors explore the management of aortic and mitral valvulopathy in patients with left ventricular assist devices. They review current practices and surgical techniques and delineate a reproducible approach to this pathology. Sometimes, the enemy of good is better. And other times, an ounce of prevention is worth a pound of cure. Maureen E. Cheung, DO, and Nahush A. Mokadam, MD Mechanical circulatory support has been established as an alternative strategy for treating patients with end-stage heart failure. In select evaluations, survival after left ventricular assist device (LVAD) implantation approaches that of cardiac transplantation.1Mehra M.R. Uriel N. Naka Y. Cleveland J.C. Yuzefpolskaya M. Salerno C.T. et al.MOMENTUM 3 InvestigatorsA fully magnetically levitated left ventricular assist device—final report.N Engl J Med. 2019; 380: 1618-1627Crossref PubMed Scopus (682) Google Scholar Still, progress in the field rests not only on innovations in device engineering but also on further optimization of clinical management strategies. In this respect, valvular dysfunction remains a challenging aspect of caring for patients with LVADs, and concomitant valvular surgery during LVAD implantation should only be undertaken by advanced programs and surgeons with experience in this area. Although there are some generally accepted indications for valvular surgery in patients requiring mechanical circulatory support (Table 1), there is a lack of consensus on if, when, and/or how one should surgically address mitral regurgitation (MR) and aortic insufficiency (AI) at the time of LVAD implantation.2Feldman D. Pamboukian S.V. Teuteberg J.J. Birks M. Lietz K. Moore S.A. et al.The 2013 International Society for Heart and Lung Transplantation Guidelines for mechanical circulatory support: executive summary.J Heart Lung Transpl. 2013; 32: 157-187Abstract Full Text Full Text PDF PubMed Scopus (1082) Google Scholar,3Kirklin J.K. Pagani F.D. Goldstein D.J. John R. Rojers J.G. Atluri P. et al.American Association for Thoracic Surgery/International Society for Heart and Lung Transplantation guidelines on selected topics in mechanical circulatory support.J Heart Lung Transpl. 2020; 39: 187-219Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar In the absence of clear guidelines, we summarize evolving evidence and offer our recommendations for approaching mitral valve (MV) and aortic valve (AV) surgery during LVAD implantation.Table 1Selected recommendations for mitral and aortic valve interventions during left ventricular assist device (LVAD) implantationRecommendationsCORLOEGeneral Treatment of coexisting valvular pathologies at the time of LVAD implant must be balanced against the anticipated duration of support.IBRecommendations for mitral valve Severe mitral insufficiency is not a contraindication to mechanical circulatory support and does not routinely require surgical repair or valve replacement, unless there is expectation of ventricular recovery.IIbC Routine mitral valve repair or replacement for severe mitral regurgitation is not recommended.IIICRecommendations for mechanical mitral valves Routine replacement of properly functioning mechanical mitral valve is not recommended.IIICRecommendations for aortic valve disease Functioning bioprosthetic valves do not require removal or replacement at the time of implant.IC A mechanical aortic valve prosthesis should either be replaced with a bioprosthesis or covered/closed with a patch at the time of LVAD implant.ICRecommendations for aortic regurgitation More than mild aortic insufficiency should prompt consideration for surgical intervention during device implantation.ICCOR, Class of recommendation: I = Evidence and/or general agreement that a given treatment or procedure is beneficial, useful, and effective; IIb = usefulness/efficacy is less well established by evidence/opinion; III = evidence or general agreement that the treatment or procedure is not useful or effective and, in some cases, may be harmful.LOE, Level of Evidence: B = data derived from a single randomized clinical trial or large non-randomized studies; C = consensus of opinion of the experts and/or small studies, retrospective studies, registries. Select guidelines and recommendations supported by the International Society for Heart and Lung Transplantation and American Association for Thoracic Surgery.2Feldman D. Pamboukian S.V. Teuteberg J.J. Birks M. Lietz K. Moore S.A. et al.The 2013 International Society for Heart and Lung Transplantation Guidelines for mechanical circulatory support: executive summary.J Heart Lung Transpl. 2013; 32: 157-187Abstract Full Text Full Text PDF PubMed Scopus (1082) Google Scholar,3Kirklin J.K. Pagani F.D. Goldstein D.J. John R. Rojers J.G. Atluri P. et al.American Association for Thoracic Surgery/International Society for Heart and Lung Transplantation guidelines on selected topics in mechanical circulatory support.J Heart Lung Transpl. 2020; 39: 187-219Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar Open table in a new tab COR, Class of recommendation: I = Evidence and/or general agreement that a given treatment or procedure is beneficial, useful, and effective; IIb = usefulness/efficacy is less well established by evidence/opinion; III = evidence or general agreement that the treatment or procedure is not useful or effective and, in some cases, may be harmful. LOE, Level of Evidence: B = data derived from a single randomized clinical trial or large non-randomized studies; C = consensus of opinion of the experts and/or small studies, retrospective studies, registries. Select guidelines and recommendations supported by the International Society for Heart and Lung Transplantation and American Association for Thoracic Surgery.2Feldman D. Pamboukian S.V. Teuteberg J.J. Birks M. Lietz K. Moore S.A. et al.The 2013 International Society for Heart and Lung Transplantation Guidelines for mechanical circulatory support: executive summary.J Heart Lung Transpl. 2013; 32: 157-187Abstract Full Text Full Text PDF PubMed Scopus (1082) Google Scholar,3Kirklin J.K. Pagani F.D. Goldstein D.J. John R. Rojers J.G. Atluri P. et al.American Association for Thoracic Surgery/International Society for Heart and Lung Transplantation guidelines on selected topics in mechanical circulatory support.J Heart Lung Transpl. 2020; 39: 187-219Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar Although clinically significant (ie, moderate or worse) functional MR is a frequent manifestation and important prognosticator of outcomes among patients with end-stage heart failure, MR typically improves after LVAD implantation.4Noly P.E. Pagani F.D. Noiseux N. Stulak J.M. Khalpey Z. Carrier M. et al.Continuous-flow left ventricular assist devices and valvular heart disease: a comprehensive review.Can J Cardiol. 2020; 36: 244-260Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar, 5Morgan J.A. Brewer R.J. Nemeh H.W. Murthy R. Williams C.T. Lanfear D.R. et al.Left ventricular reverse remodeling with a continuous flow left ventricular assist device measured by left ventricular end-diastolic dimensions and severity of mitral regurgitation.ASAIO J. 2012; 58: 574-577Crossref PubMed Scopus (56) Google Scholar, 6Kanwar M.K. Rajagopal K. Itoh A. Silvestry S.C. Uriel N. Cleveland J.C. et al.Impact of left ventricular assist device implantation on mitral regurgitation: an analysis from the MOMENTUM 3 trial.J Heart Lung Transpl. 2020; 39: 529-537Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar For example, in a recent analysis of patients enrolled in the MOMENTUM 3 trial, although significant MR was present in nearly one half of patients before LVAD implantation, it persisted in just ∼5% to 15% at 1 month after surgery and rarely progressed at 2 years of follow-up.6Kanwar M.K. Rajagopal K. Itoh A. Silvestry S.C. Uriel N. Cleveland J.C. et al.Impact of left ventricular assist device implantation on mitral regurgitation: an analysis from the MOMENTUM 3 trial.J Heart Lung Transpl. 2020; 39: 529-537Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar In large part, this is because LVADs decompress the left ventricle, which improves MV geometry and leaflet coaptation almost immediately by reversing annular dilatation and leaflet restriction. In addition, continuous offloading of ventricular wall stress can facilitate reverse myocyte remodeling to promote a sustained reduction in MR.4Noly P.E. Pagani F.D. Noiseux N. Stulak J.M. Khalpey Z. Carrier M. et al.Continuous-flow left ventricular assist devices and valvular heart disease: a comprehensive review.Can J Cardiol. 2020; 36: 244-260Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar,5Morgan J.A. Brewer R.J. Nemeh H.W. Murthy R. Williams C.T. Lanfear D.R. et al.Left ventricular reverse remodeling with a continuous flow left ventricular assist device measured by left ventricular end-diastolic dimensions and severity of mitral regurgitation.ASAIO J. 2012; 58: 574-577Crossref PubMed Scopus (56) Google Scholar,7Wang T.S. Hernandez A.F. Felker G.M. Milano C.A. Rogers J.G. Patel C.B. Valvular heart disease in patients supported with left ventricular assist devices.Circ Heart Fail. 2014; 7: 215-222Crossref PubMed Scopus (52) Google Scholar This may provide some explanation for why 2-year survival rates after LVAD implantation, which have been estimated at ∼70% to 80%, appear unaffected by the presence and/or severity of pre-existing MR.6Kanwar M.K. Rajagopal K. Itoh A. Silvestry S.C. Uriel N. Cleveland J.C. et al.Impact of left ventricular assist device implantation on mitral regurgitation: an analysis from the MOMENTUM 3 trial.J Heart Lung Transpl. 2020; 39: 529-537Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar,8Stulak J.M. Tchantchaleishvili V. Haglund N.A. Davis M.E. Schirger J.A. Cowger J.A. et al.Uncorrected pre-operative mitral valve regurgitation is not associated with adverse outcomes after continuous-flow left ventricular assist device implantation.J Heart Lung Transpl. 2015; 34: 718-723Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar Still, it is evident that some patients will have significant MR that persists after LVAD implantation, and MR may even recur despite initial resolution.5Morgan J.A. Brewer R.J. Nemeh H.W. Murthy R. Williams C.T. Lanfear D.R. et al.Left ventricular reverse remodeling with a continuous flow left ventricular assist device measured by left ventricular end-diastolic dimensions and severity of mitral regurgitation.ASAIO J. 2012; 58: 574-577Crossref PubMed Scopus (56) Google Scholar,6Kanwar M.K. Rajagopal K. Itoh A. Silvestry S.C. Uriel N. Cleveland J.C. et al.Impact of left ventricular assist device implantation on mitral regurgitation: an analysis from the MOMENTUM 3 trial.J Heart Lung Transpl. 2020; 39: 529-537Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar,8Stulak J.M. Tchantchaleishvili V. Haglund N.A. Davis M.E. Schirger J.A. Cowger J.A. et al.Uncorrected pre-operative mitral valve regurgitation is not associated with adverse outcomes after continuous-flow left ventricular assist device implantation.J Heart Lung Transpl. 2015; 34: 718-723Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar, 9Robertson J.O. Naftel D.C. Myers S.L. Tedford R.J. Joseph S.M. Kirklin J.K. et al.Concomitant mitral valve procedures in patients undergoing implantation of continuous-flow left ventricular assist devices: an INTERMACS database analysis.J Heart Lung Transpl. 2018; 37: 79-88Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar, 10Taghavi S. Hamad E. Wilson L. Clark R. Jayarajan S.N. Uriel N. et al.Mitral valve repair at the time of continuous-flow left ventricular assist device implantation confers meaningful decrement in pulmonary vascular resistance.ASAIO J. 2013; 59: 469-473Crossref PubMed Scopus (50) Google Scholar, 11Choi J.H. Luc J.G.Y. Moncho Escrivá E. Phan K. Rizvi S.S.A. Patel S. et al.Impact of concomitant mitral valve surgery with LVAD placement: systematic review and meta-analysis.Artif Organs. 2018; 42: 1139-1147Crossref PubMed Scopus (18) Google Scholar, 12Kassis H. Cherukuri K. Agarwal R. Kanwar M. Elapavaluru S. Sokos G.G. et al.Significance of residual mitral regurgitation after continuous flow left ventricular assist device implantation.JACC Heart Fail. 2017; 5: 81-88Crossref PubMed Scopus (68) Google Scholar Although several studies have suggested that residual MR persisting after LVAD implantation does not adversely affect functional status, readmission rates, or survival, others have refuted these assertions and have associated worse outcomes with persistent pulmonary hypertension and right ventricular dysfunction.5Morgan J.A. Brewer R.J. Nemeh H.W. Murthy R. Williams C.T. Lanfear D.R. et al.Left ventricular reverse remodeling with a continuous flow left ventricular assist device measured by left ventricular end-diastolic dimensions and severity of mitral regurgitation.ASAIO J. 2012; 58: 574-577Crossref PubMed Scopus (56) Google Scholar,6Kanwar M.K. Rajagopal K. Itoh A. Silvestry S.C. Uriel N. Cleveland J.C. et al.Impact of left ventricular assist device implantation on mitral regurgitation: an analysis from the MOMENTUM 3 trial.J Heart Lung Transpl. 2020; 39: 529-537Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar,8Stulak J.M. Tchantchaleishvili V. Haglund N.A. Davis M.E. Schirger J.A. Cowger J.A. et al.Uncorrected pre-operative mitral valve regurgitation is not associated with adverse outcomes after continuous-flow left ventricular assist device implantation.J Heart Lung Transpl. 2015; 34: 718-723Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar,12Kassis H. Cherukuri K. Agarwal R. Kanwar M. Elapavaluru S. Sokos G.G. et al.Significance of residual mitral regurgitation after continuous flow left ventricular assist device implantation.JACC Heart Fail. 2017; 5: 81-88Crossref PubMed Scopus (68) Google Scholar, 13Sugiura T. Kurihara C. Kawabori M. Critsinelis A.C. Wang S. Civitello A.B. et al.Concomitant valve procedures in patients undergoing continuous-flow left ventricular assist device implantation: a single-center experience.J Thorac Cardiovasc Surg. 2019; 158: 1083-1089.e1Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar, 14Tanaka A. Onsager D. Song T. Cozadd D. Kim G. Sarswat N. et al.Surgically corrected mitral regurgitation during left ventricular assist device implantation is associated with low recurrence rate and improved midterm survival.Ann Thorac Surg. 2017; 103: 725-733Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar, 15Tang P.C. Haft J.W. Romano M.A. Bitar A. Hasan R. Palardy M. et al.Right ventricular function and residual mitral regurgitation after left ventricular assist device implantation determines the incidence of right heart failure.J Thorac Cardiovasc Surg. 2020; 159: 897-905.e4Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar These discrepancies are likely multifactorial and represent the inherent challenges of drawing broad conclusions from investigations that have significant heterogeneity in patient populations, interdependent risk factors, and variable medical and surgical management strategies. However, recent investigations have provided important insight into these nuanced relationships. For example, although residual moderate-to-severe MR may be well-tolerated in patients with LVADs, its coexistence with right ventricular dysfunction appears to portend greater morbidity and mortality and reduces 5-year survival from ∼55% to <20%.15Tang P.C. Haft J.W. Romano M.A. Bitar A. Hasan R. Palardy M. et al.Right ventricular function and residual mitral regurgitation after left ventricular assist device implantation determines the incidence of right heart failure.J Thorac Cardiovasc Surg. 2020; 159: 897-905.e4Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar In stark contrast to MR, significant (ie, moderate or worse) AI is relatively uncommon in end-stage heart failure, yet it often worsens after LVAD implantation. Whereas the prevalence of mild AI before LVAD implantation has been cited at ∼20% to 30%, moderate or worse AI may be present in just ∼5% of patients at the time of referral for cardiac transplantation or mechanical circulatory support.4Noly P.E. Pagani F.D. Noiseux N. Stulak J.M. Khalpey Z. Carrier M. et al.Continuous-flow left ventricular assist devices and valvular heart disease: a comprehensive review.Can J Cardiol. 2020; 36: 244-260Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar,7Wang T.S. Hernandez A.F. Felker G.M. Milano C.A. Rogers J.G. Patel C.B. Valvular heart disease in patients supported with left ventricular assist devices.Circ Heart Fail. 2014; 7: 215-222Crossref PubMed Scopus (52) Google Scholar,13Sugiura T. Kurihara C. Kawabori M. Critsinelis A.C. Wang S. Civitello A.B. et al.Concomitant valve procedures in patients undergoing continuous-flow left ventricular assist device implantation: a single-center experience.J Thorac Cardiovasc Surg. 2019; 158: 1083-1089.e1Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar,16John R. Mantz K. Eckman P. Rose A. May-Newman K. Aortic valve pathophysiology during left ventricular assist device support.J Heart Lung Transpl. 2010; 29: 1321-1329Abstract Full Text Full Text PDF PubMed Scopus (153) Google Scholar, 17Tanaka Y. Nakajima T. Fischer I. Wan F. Kotkar K. Moon M.R. et al.The impact of uncorrected mild aortic insufficiency at the time of left ventricular assist device implantation.J Thorac Cardiovasc Surg. 2020; 160: 1490-1500.e3Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar, 18Robertson J.O. Naftel D.C. Myers S.L. Prasad S. Mertz G.D. Itoh A. et al.Concomitant aortic valve procedures in patients undergoing implantation of continuous-flow left ventricular assist devices: an INTERMACS database analysis.J Heart Lung Transpl. 2015; 34: 797-805Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar, 19Truby L.K. Garan A.R. Givens R.C. Wayda B. Takeda K. Yuzefpolskaya M. et al.Aortic insufficiency during contemporary left ventricular assist device support: analysis of the INTERMACS Registry.JACC Heart Fail. 2018; 6: 951-960Crossref PubMed Scopus (97) Google Scholar, 20Holley C.T. Fitzpatrick M. Roy S.S. Alraies M.C. Cogswell R. Souslian L. et al.Aortic insufficiency in continuous-flow left ventricular assist device support patients is common but does not impact long-term mortality.J Heart Lung Transpl. 2017; 36: 91-96Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar Meanwhile, the proportion of patients with significant AI may increase to ∼20% to 50% within 1 to 2 years after LVAD implantation, which some evidence has suggested occurs irrespective of the existence of AI or its degree of severity before surgery.4Noly P.E. Pagani F.D. Noiseux N. Stulak J.M. Khalpey Z. Carrier M. et al.Continuous-flow left ventricular assist devices and valvular heart disease: a comprehensive review.Can J Cardiol. 2020; 36: 244-260Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar,7Wang T.S. Hernandez A.F. Felker G.M. Milano C.A. Rogers J.G. Patel C.B. Valvular heart disease in patients supported with left ventricular assist devices.Circ Heart Fail. 2014; 7: 215-222Crossref PubMed Scopus (52) Google Scholar,17Tanaka Y. Nakajima T. Fischer I. Wan F. Kotkar K. Moon M.R. et al.The impact of uncorrected mild aortic insufficiency at the time of left ventricular assist device implantation.J Thorac Cardiovasc Surg. 2020; 160: 1490-1500.e3Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar, 18Robertson J.O. Naftel D.C. Myers S.L. Prasad S. Mertz G.D. Itoh A. et al.Concomitant aortic valve procedures in patients undergoing implantation of continuous-flow left ventricular assist devices: an INTERMACS database analysis.J Heart Lung Transpl. 2015; 34: 797-805Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar, 19Truby L.K. Garan A.R. Givens R.C. Wayda B. Takeda K. Yuzefpolskaya M. et al.Aortic insufficiency during contemporary left ventricular assist device support: analysis of the INTERMACS Registry.JACC Heart Fail. 2018; 6: 951-960Crossref PubMed Scopus (97) Google Scholar, 20Holley C.T. Fitzpatrick M. Roy S.S. Alraies M.C. Cogswell R. Souslian L. et al.Aortic insufficiency in continuous-flow left ventricular assist device support patients is common but does not impact long-term mortality.J Heart Lung Transpl. 2017; 36: 91-96Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar, 21Rajagopal K. Daneshmand M.A. Patel C.B. Ganapathi A.M. Schechter M.A. Rogers J.G. et al.Natural history and clinical effect of aortic valve regurgitation after left ventricular assist device implantation.J Thorac Cardiovasc Surg. 2013; 145: 1373-1379Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar Among other contributing factors, this is because supravalvular outflow delivered from the LVAD elevates the transaortic valve pressure gradient, which increases resistance to AV opening and ejection from the left ventricle. This alters the biomechanics of the AV apparatus and can directly traumatize AV leaflets, leading to new and/or progressive AI after LVAD implantation.4Noly P.E. Pagani F.D. Noiseux N. Stulak J.M. Khalpey Z. Carrier M. et al.Continuous-flow left ventricular assist devices and valvular heart disease: a comprehensive review.Can J Cardiol. 2020; 36: 244-260Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar,7Wang T.S. Hernandez A.F. Felker G.M. Milano C.A. Rogers J.G. Patel C.B. Valvular heart disease in patients supported with left ventricular assist devices.Circ Heart Fail. 2014; 7: 215-222Crossref PubMed Scopus (52) Google Scholar,16John R. Mantz K. Eckman P. Rose A. May-Newman K. Aortic valve pathophysiology during left ventricular assist device support.J Heart Lung Transpl. 2010; 29: 1321-1329Abstract Full Text Full Text PDF PubMed Scopus (153) Google Scholar In addition, commissural leaflet fusion by limited AV opening can further restrict leaflet mobility, thereby resulting in de novo AI. Although these effects are exacerbated at greater flows and with full LVAD support, even partial support with lower flows can still contribute to the development and/or progression of valvular and ventricular dysfunction over time.4Noly P.E. Pagani F.D. Noiseux N. Stulak J.M. Khalpey Z. Carrier M. et al.Continuous-flow left ventricular assist devices and valvular heart disease: a comprehensive review.Can J Cardiol. 2020; 36: 244-260Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar,7Wang T.S. Hernandez A.F. Felker G.M. Milano C.A. Rogers J.G. Patel C.B. Valvular heart disease in patients supported with left ventricular assist devices.Circ Heart Fail. 2014; 7: 215-222Crossref PubMed Scopus (52) Google Scholar,16John R. Mantz K. Eckman P. Rose A. May-Newman K. Aortic valve pathophysiology during left ventricular assist device support.J Heart Lung Transpl. 2010; 29: 1321-1329Abstract Full Text Full Text PDF PubMed Scopus (153) Google Scholar,21Rajagopal K. Daneshmand M.A. Patel C.B. Ganapathi A.M. Schechter M.A. Rogers J.G. et al.Natural history and clinical effect of aortic valve regurgitation after left ventricular assist device implantation.J Thorac Cardiovasc Surg. 2013; 145: 1373-1379Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar Importantly, any degree of AI after LVAD implantation creates a short circulatory loop of retrograde flow through the AV, such that the device must generate greater output to provide the same amount of systemic hemodynamic support. With this perspective, it is not surprising that significant AI after LVAD implantation increases hospital readmission and mortality rates. For example, we observed that 2-year mortality increased from ∼10% to >40% among patients with either no or mild AI compared with those with moderate AI at 6 months after LVAD implantation, respectively.22Auvil B. Chung J. Ameer A. Han J. Helmers M. Birati E. et al.Moderate aortic insufficiency with a left ventricular assist device portends a worse long-term survival.ASAIO J. 2020; 66: 780-785Crossref PubMed Scopus (8) Google Scholar Others have demonstrated that once significant AI develops, 5-year survival may decline from ∼50% to ∼35%.19Truby L.K. Garan A.R. Givens R.C. Wayda B. Takeda K. Yuzefpolskaya M. et al.Aortic insufficiency during contemporary left ventricular assist device support: analysis of the INTERMACS Registry.JACC Heart Fail. 2018; 6: 951-960Crossref PubMed Scopus (97) Google Scholar Even among patients surviving to 1 year after LVAD implantation, the presence of significant AI has been observed to reduce 2-year survival from ∼75% to ∼70%.19Truby L.K. Garan A.R. Givens R.C. Wayda B. Takeda K. Yuzefpolskaya M. et al.Aortic insufficiency during contemporary left ventricular assist device support: analysis of the INTERMACS Registry.JACC Heart Fail. 2018; 6: 951-960Crossref PubMed Scopus (97) Google Scholar Although other investigations have failed to consistently demonstrate significant associations between the presence/severity of AI after LVAD implantation and outcomes pertaining to quality of life and/or survival,20Holley C.T. Fitzpatrick M. Roy S.S. Alraies M.C. Cogswell R. Souslian L. et al.Aortic insufficiency in continuous-flow left ventricular assist device support patients is common but does not impact long-term mortality.J Heart Lung Transpl. 2017; 36: 91-96Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar,21Rajagopal K. Daneshmand M.A. Patel C.B. Ganapathi A.M. Schechter M.A. Rogers J.G. et al.Natural history and clinical effect of aortic valve regurgitation after left ventricular assist device implantation.J Thorac Cardiovasc Surg. 2013; 145: 1373-1379Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar these discrepancies may be partially due to the fact that, until recently, there was a relative paucity of large studies including patients with LVADs as destination therapy.18Robertson J.O. Naftel D.C. Myers S.L. Prasad S. Mertz G.D. Itoh A. et al.Concomitant aortic valve procedures in patients undergoing implantation of continuous-flow left ventricular assist devices: an INTERMACS database analysis.J Heart Lung Transpl. 2015; 34: 797-805Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar,19Truby L.K. Garan A.R. Givens R.C. Wayda B. Takeda K. Yuzefpolskaya M. et al.Aortic insufficiency during contemporary left ventricular assist device support: analysis of the INTERMACS Registry.JACC Heart Fail. 2018; 6: 951-960Crossref PubMed Scopus (97) Google Scholar In addition, important questions have recently been raised regarding whether even mild pre-existing AI at the time of LVAD implantation may contribute to progressive valvular dysfunction and adverse postoperative outcomes. Although current evidence is limited, significant AI may be more than twice as likely to develop in patients with mild preimplantation AI compared with those with none.17Tanaka Y. Nakajima T. Fischer I. Wan F. Kotkar K. Moon M.R. et al.The impact of uncorrected mild aortic insufficiency at the time of left ventricular assist device implantation.J Thorac Cardiovasc Surg. 2020; 160: 1490-1500.e3Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar,19Truby L.K. Garan A.R. Givens R.C. Wayda B. Takeda K. Yuzefpolskaya M. et al.Aortic insufficiency during contemporary left ventricular assist device support: analysis of the INTERMACS Registry.JACC Heart Fail. 2018; 6: 951-960Crossref PubMed Scopus (97) Google Scholar For example, Tanaka and colleagues17Tanaka Y. Nakajima T. Fischer I. Wan F. Kotkar K. Moon M.R. et al.The impact of uncorrected mild aortic insufficiency at the time of left ventricular assist device implantation.J Thorac Cardiovasc Surg. 2020; 160: 1490-1500.e3Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar recently demonstrated that the incidence of moderate AI after LVAD implantation increases from ∼10% to almost 50% when comparing patients with none or trace preimplantation AI with those with only mild preimplantation AI, respectively. Although 2-year complication rates and survival were similar between the groups, patients with mild AI had significantly worse funct