Percutaneous LVADs Can Spur Aortic Regurgitation, Small Study Cautions

For some patients, a percutaneous left ventricular assist device (LVAD) may increase the risk of subsequent aortic regurgitation (AR), especially when there’s a need for longer support, new data suggest.

The single-center study, published as a research letter in JACC: Cardiovascular Interventions, with lead author Jad Zeitoun, MD (Houston Methodist Hospital, TX), found 13% of patients had new or worsened AR after removal of the LVAD. It presented as mild in most, but progressed to moderate or moderate-severe AR in 3%.

Senior author Maan Malahfji, MD (Houston Methodist Hospital), told TCTMD that while AR after percutaneous LVAD support is known to be an infrequent occurrence, its incidence hadn’t yet been examined systematically in the literature.

“We’ve had patients who ended up developing AR after recovering from heart failure and having the LVAD taken out. One patient who transitioned to a permanent LVAD ended up with significant AR that eventually required a transcatheter valve procedure,” he said, adding that larger mechanical support devices like the Impella 5.5 (Abiomed) have become more commonly used in patients with advanced heart failure and deserved a closer look.

“We don’t think there’s any reason for alarm just yet, but it’s something that we should be more cognizant of . . . and look at in a larger cohort, ideally prospectively, where patients get serial echoes over time: during the initial hospitalization and then over the ensuing year as they recover,” Malahfji suggested.

Continued Monitoring Encouraged

The study, performed at Houston Methodist, included 98 patients (median age 63.8 years; 32% women) who were on LVAD support for a median of 7 days between 2014 and 2024. All patients had transthoracic echocardiography (TTE) data available from before percutaneous LVAD placement and at a median of 83 days after removal. The majority were on smaller devices (Impella CP and Impella 2.5; Abiomed), with the remaining one third of patients on larger devices (Impella 5.0 and Impella 5.5).

The reason for support was cardiogenic shock in 55%, ACS-related shock in 24%, cardiac arrest in 15%, and high-risk procedures in 6%. Most patients (69%) had no AR prior to LVAD placement, while 30% had mild and 1% had moderate aortic regurgitation with central jets. No cases of aortic root aneurysm or annular dilatation were seen.

Patients who had new or worsened AR versus those who didn’t were no more likely to have intraprocedural complications during implantation or removal. Of those who had moderate or moderate-severe AR, two died after multiorgan failure and a third remains under surveillance, the researchers note.

Compared with patients who did not have new or worsened AR, those who did had longer support duration times (median 12 vs 6 days; P = 0.032). The same was seen in those who did versus did not develop moderate or moderate-severe AR (median 51 vs 6 days; P = 0.046). In this group, use of large-bore versus smaller devices also was associated with greater risk of progression (P = 0.033).

One commonality among about one-third of the cases of new or worsened AR, however, was that cardiac arrest was the indication for the LVAD.

But Why the Risk?

Malahfji said no visible leaflet damage was seen on imaging and no surgical evaluation of the valves was undertaken.

“This is purely a hypothesis, but it may be that because of the extended contact against the Impella [there is] some underlying leaflet fibrosis or low-grade inflammation that occurs and leads to reduced coaptation once the Impella is taken out,” he added.

Overall, Malahfji said, the study is a good reminder to follow instructions for Impella use with regard to the length of time patients should be on the device and to being cautious about using it in those with moderate or greater AR.

“Very often [LVAD] is used in an extremist-type situation where the patient doesn’t have any other options,” he noted. “So, the reality in our hospital and many others is that patients do need support for longer duration[s]. We need to be cognizant [that] if someone has underlying annular dilation or preexisting mild AR, and you know that this patient is going to need extended duration of support, you should continue to monitor them once they recover and the Impella is taken out.”