Challenges in Heart Failure Surgery: Rescue Therapy with Left Ventricular Assist Device Implantation and Four Concomitant Procedures in a High-Risk Patient with Decompensating Heart Failure

Introduction: Whereas it is recognized that additional surgery along with LVAD implantation increase the complexity of procedure, there are still no guidelines for concomitant procedures. We present a case of LVAD (HVAD, HeartWare, Inc., Framingham, MA, USA) implantation, tricuspid valve reconstruction (TVR), aortic valve replacement (AVR), patent foramen ovale (PFO) closure and radiofrequency ablation in a high-risk patient with decompensating heart failure.

Background: A 71-year-old male with end-stage heart failure based on ischemic cardiomyopathy and multiple myocardial infarctions was referred to our center for consideration of LVAD therapy. Due to his decompensating condition and additional comorbidities, particularly severe aortic valve stenosis, severe tricuspid valve insufficiency, mitral valve insufficiency despite two mitral clips, cardio-renal syndrome with stage IV chronic kidney disease, atrial fibrillation and flutter as well as severely compromised right ventricular function with dilated right ventricle and poor longitudinal contractility (TAPSE 11 mm), the procedure planned was graded as a high-risk rescue therapy. The procedure was performed on-pump through median sternotomy. Initially, no aortic valve replacement was planned as only mild aortic valve insufficiency was described on preoperative echocardiography. Thus, to avoid cardioplegic arrest, tricuspid valve reconstruction with a 30 mm Carpentier Edwards Physio tricuspid annuloplasty ring (Edwards Lifescience, Irvine, CA, USA) was performed following radiofrequency ablation and PFO closure on beating heart. After subsequent HVAD implantation the patient could be rapidly weaned off cardiopulmonary bypass with even improving right ventricular function. However, a new significant aortic regurgitation was noted on the transesophageal echocardiography leading to increasing recirculation. Thus, an additional aortic valve replacement using a 23 mm Carpentier-Edwards Perimount valve (Edwards Lifesciences, Irvine, CA, United States) was performed in a 29-minute cardioplegic arrest. After postoperative recovery, the patient was discharged from hospital and has been doing well for one year of follow-up.

Discussion: This case shows that multiple concomitant procedures along with LVAD implantation are possible and even advantageous in selected patients. However, cardioplegic arrest should be kept as short as possible particularly in patients with poor preoperative right ventricular function.