Managing Aortic Regurgitation and Dynamic Aortic Thrombus in a Patient With Left Ventricular Assist Device

Patients with end-stage heart failure undergoing durable left ventricular assist device (dLVAD) implantation are at risk of developing de novo or progressive aortic regurgitation (AR) during long-term support.

We report a dLVAD patient with significant AR, in whom transcatheter aortic valve replacement was unsuitable because of an enlarged aortic annulus and aortic thrombus. A complex hybrid approach included open thrombus removal from the ascending aorta under short circulatory arrest, temporary interventional occlusion of a not-accessible dLVAD outflow-graft, and surgical aortic valve replacement (SAVR).

Aortic thrombus in dLVAD patients carries the risk of coronary, cerebral or peripheral embolism. In addition to this contraindication, SAVR was favored over transcatheter aortic valve replacement because of an aortic annulus diameter >28 mm, according to the institutional treatment algorithm.

In a dLVAD patient with AR and aortic thrombus, an individualized hybrid strategy enabled effective outflow-graft occlusion facilitating safe thrombus evacuation and SAVR.