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Case report of increased left ventricular end-diastolic pressure with pulsatile left ventricular assist device
Mauricio Felippi de Sá Marchi1,2, Sarah Verhemel1, Rutger-Jan Nuis1
1Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands.
Insights
A pulsatile left ventricular assist device (LVAD) unexpectedly raised left ventricular end-diastolic pressure during transcatheter aortic valve implantation. This case highlights potential complications of LVAD use in complex cardiac procedures.
Area of Science:
- Cardiology
- Cardiovascular Surgery
- Interventional Cardiology
Background:
- Left ventricular assist devices (LVADs) are crucial for managing cardiogenic shock and high-risk percutaneous coronary interventions (PCIs).
- LVADs function by draining the left ventricle (LV) and augmenting aortic flow, typically lowering left ventricular end-diastolic pressure (LVEDP).
- This case involves a patient with severe aortic stenosis and multi-vessel coronary artery disease undergoing transcatheter aortic valve implantation (TAVI) and PCI with LVAD support.
Observation:
- A patient experienced unexpected shortness of breath and elevated LVEDP while supported by a pulsatile LVAD during TAVI and PCI.
- These symptoms and pressure elevations resolved immediately upon LVAD removal.
- The pulsatile LVAD utilizes a bi-directional flow catheter for cardiac output enhancement.
Findings:
- Contrary to expectations, the LVAD resulted in increased LVEDP and patient distress.
- The observed LVEDP rise and symptoms suggest a complication related to the LVAD's interaction with the aortic valve.
- This interaction may lead to aortic leaflet immobilization and acute aortic regurgitation.
Implications:
- This case underscores the potential for unexpected hemodynamic complications with LVAD use in conjunction with TAVI.
- It highlights the importance of careful monitoring and consideration of LVAD-aortic valve interaction during complex interventional procedures.
- Further investigation into the mechanics of pulsatile LVADs and their impact on aortic valve function is warranted.
Background:
Left ventricular assist devices (LVADs) are increasingly utilized in cardiogenic shock and high-risk percutaneous coronary interventions (PCIs). These devices aspirate and expel blood from the left ventricle (LV) into the aorta, consequently reducing left ventricular end-diastolic pressure (LVEDP). We report a case of unexpected LVEDP rise under LV-to-aorta LVAD in the context of transcatheter aortic valve implantation (TAVI) and concomitant multi-vessel PCI.
Case Summary:
A patient with acute heart failure, severely depressed systolic LV function, severe aortic stenosis, and multi-vessel coronary artery disease underwent TAVI and concomitant PCI under pulsatile LVAD. Notably, the patient experienced unexpected shortness of breath and elevated LVEDP while under LVAD, which normalized immediately upon LVAD removal.
Discussion:
Pulsatile LVAD enhances cardiac output by providing pulsatile support through a percutaneous bi-directional flow catheter. Despite expectations of reduced LVEDP and improved myocardial oxygen supply under LVAD support, we observed high LVEDP and clinical complaints of shortness of breath following TAVI and multi-vessel PCI. This case illustrates that an LVAD across the aortic valve may immobilize aortic leaflets and generate acute aortic regurgitation.
