Aortic regurgitation in left ventricular assist device patients - Does aortic root dilatation contribute to valve incompetence?

BackgroundAortic regurgitation (AR) is a known complication after left ventricular assist device (LVAD) implantation potentially leading to recurrent heart failure. Possible pathomechanisms include valvular pathologies and aortic root dilatation. We assessed aortic root dimensions in a group of consecutive LVAD patients who received HeartMate 3.MethodsSince 11/2015, we identified 68 patients with no or mild AR at the time of HeartMate 3 implantation who underwent serial echocardiography to assess AR and aortic root dimensions (annulus, sinus, and sinotubular junction). Median follow-up was 40 months (2-94 months). Results were correlated with clinical outcomes.ResultsPatients were 60 +/- 10 years old, predominantly male (88%) and 35% presented in preoperative critical condition as defined by INTERMACS levels 1 and 2. During follow-up, 23 patients developed AR >= II (34%). Actuarial incidence was 8% at 1 year, 29% at 3 years and 41% at 5 years. Echocardiography revealed practically stable root dimensions at the latest follow-up compared to the preoperative state (annulus: 23 +/- 3 mm vs. 23 +/- 2 mm, sinus: 32 +/- 4 mm vs. 33 +/- 3 mm, sinotubular junction: 27 +/- 3 mm vs. 28 +/- 3 mm), irrespective of the development of AR. Serial CT angiograms were performed in 13 patients to confirm echocardiographic findings. Twenty-one patients died during LVAD support leading to a 5-year survival of 71%, showing no difference between patients with and without AR >= II (p = 0.573).ConclusionsAt least moderate AR develops over time in a substantial fraction of patients (one-third over 3 years). The mechanism does not seem to be related to dilatation of the aortic annulus or root. Aortic regurgitation (AR) frequently occurs after left ventricular assist device implantation with aortic root dilatation being one potential pathomechanism. In patients after HeartMate 3 implantation, no significant aortic dilatation could be found by echocardiography and CT angiogram, thus, favoring a valvular pathomechanism causing AR.image