Aortic insufficiency progression in patients with left ventricular assist devices and prior Impella support

While Impella percutaneous temporary left ventricular assist devices (LVADs) have revolutionized the management of cardiogenic shock, the incidence and risk factors for aortic insufficiency (AI) remain unclear.

This single-center, retrospective cohort study evaluated the risk of AI in all patients who received Impella support, Impella with subsequent durable LVAD (Impella+LVAD), and durable LVAD without prior Impella support between January 1, 2019 and August 31, 2023. Given the distinct clinical pathways among these groups, analyses were conducted using 2 separate frameworks. Impella Framework: patients without progressive AI before Impella implantation were included. Incidence of progressive AI was compared between the Impella+LVAD and Impella-Only groups. LVAD Framework: patients without progressive AI before LVAD implantation were included. Incidence of progressive AI was compared between the Impella+LVAD and LVAD-Only groups. In both analyses, progressive AI (moderate or severe AI on echo) was the primary endpoint, and risk factors for progressive AI were evaluated with multivariable modeling.

During the study period, 315 patients received ≥1 Impella, and 167 underwent LVAD implantation. In the Impella Framework, progressive AI incidence was higher in the Impella+LVAD group (n = 59) than in the Impella-Only group (n = 256) at both 12 months (36.4% vs 12.1%) and 24 months (46.8% vs 12.1%; aHR: 3.27, 95% cumulative incidence [CI]: 1.57-6.82, p = 0.002). In the LVAD Framework, progressive AI incidence in the Impella+LVAD group (n = 46) was also higher than in the LVAD-Only group (n = 121) at 12 (16.6% vs 0.9%) and 24 months (46.8% vs 12.1%; aHR: 7.87, 95% CI: 2.66-23.25, p < 0.001).

Prior Impella support was associated with an increased risk of progressive AI after LVAD implantation; this hypothesis-generating finding warrants prospective studies to evaluate whether a lower threshold for aortic valve replacement at the time of LVAD implantation could improve outcomes.