2019 Scientific Sessions

Title: TAVR To Treat Severe Aortic Insufficiency In Patient With LVAD and Cardiogenic Shock Introduction: TAVR has proven effectiveness in severe aortic stenosis, and it has recently emerged as an alternative to surgical replacement for patients with native aortic valve regurgitation and those with failing surgical heart valves. Clinical Case: 63 year old female with Past medical history of dilated cardiomyopathy, diabetes, and Heart Mate II left ventricular assist device (LVAD) for destination therapy placed 5 years ago. The patient developed progressive heart failure symptoms beginning one month prior to presentation. Evaluation at an outside facility revealed severe aortic insufficiency (AI) and normal LVAD function. She was transferred to our facility intubated and in profound cardiogenic shock with multi-organ failure despite maximum inotropic and pressor support.Veno-arterial extracorporeal membrane oxygenation (ECMO) via femoral artery and vein was initiated, resulting in improvement of acidosis and end organ perfusion. A transesophageal echocardiogram (TEE) confirmed appropriate LVAD function, severe AI, and a dilated left ventricle. Society of Thoracic Surgery (STS) score for mortality with surgical aortic valve replacement was 88%. Discussion: A decision was made to place a self-expanding transcatheter heart valve to treat the AI in order to improve the cardiogenic shock. TEE sizing of the annulus (performed because the patient was too unstable to move to the CT scanner) measured an annulus of 29mm. A 29 mm Evolut Pro valve was placed. ECMO and HeartMate II flows were turned down to prevent suction effect during valve deployment. The patient was observed for 10-15 minutes at 80% deployment and after full deployment to evaluate for valve migration into LVOT. The valve did migrate and therefore a Sapien 3 valve was placed inside the Evolut R valve to stabilize and anchor both valves. The intrinsic LVAD function was interrogated with multiple ramp studies afterward and demonstrated LVAD inflow obstruction. Thus, pump exchange to a HeartMate III was performed via a left thoracotomy. At the time of the operation clot was noted around the inflow cannula as well on the prosthetic aortic valve. The patient did well post-operatively, with improvement in hemodynamics and resolution of cardiogenic shock. Unfortunately, the patient later suffered a large embolic stroke and care was eventually withdrawn by the family.