Aortic insufficiency and right heart failure in patients treated with durable left ventricular assist devices after...

Temporary mechanical circulatory support (tMCS) with microaxial flow pumps (mAFP) reverses the shock state and improves hemodynamics prior to durable left ventricular assist device (dLVAD) implant. Aortic insufficiency (AI) and right heart failure (RHF) are recognized sourced of late morbidity and mortality during dLVAD support. We examined the impact of tMCS with mAFP on AI and RHF progression given their transaortic deployment and unique interaction with the aortic valve and right ventricle.

The Society of Thoracic Surgeons Intermacs Database was queried for all fully magnetically levitated centrifugal pump adult implants between 11-2020 and 12-2024. Patients with ≥ moderate preoperative AI or with concomitant aortic valve repair at dLVAD implant were excluded from the AI analysis and patients with concomitant RVADs were excluded from the RHF analysis. The impact of mAFP use prior to dLVAD implant on the development of post-implant AI and RHF was explored through Cox multivariable analysis and propensity score (PS) matching. Hazard ratio with 95% confidence interval (HR [95% CI]) is shown.

Among 5,942 patients included in the AI analysis, there were 1,936 (32.6%) with no tMCS, 1,979 (33.3%) with intra-aortic balloon pump, 1,627 (27.4%) with mAFP, and 400 (6.7%) with veno-arterial extracorporeal membrane oxygenation prior to dLVAD. After adjustment for other risk factors, mAFP support pre-dLVAD was associated with lower freedom from ≥ moderate AI at 24 months (Cox HR 1.79 [1.43-2.24]). After PSM, mAFP patients were more likely to develop ≥ moderate AI at 2 years compared to non-tMCS patients (21.4% vs 15.3%; HR 1.75 [CI 1.29-2.38]). 6,079 patients were included in the RHF analysis, of which 1,220 (20.1%) developed RHF within 24 months of dLVAD implant. Patients supported with mAFPs prior to dLVAD had an increased risk of developing RHF after dLVAD (HR = 1.33 [1.15-1.54]). After adjustment for other risk factors for RHF, mAFP support pre-dLVAD was associated with greater likelihood of RHF at 24 months (HR 1.34 [1.16-1.55]). After PSM, there was a trend for development of RHF in dLVAD patients supported with preoperative mAFP (HR 1.20 [0.97-1.49]).

Microaxial flow pump support prior to contemporary dLVAD implantation is associated with the development of moderate or worse de novo AI and may confer increased risk for RHF. Potential mechanisms, including damage to the valve apparatus and masking of clinically significant AI at the time of dLVAD, warrant further exploration.