Surgical management of valvular disease in patients requiring left ventricular assist device support

Background. Success with long-term implantable left ventricular assist devi ces (LVAD) has led to increased use in patients previously thought to be un suitable for mechanical circulatory assistance. Patients with preexisting o r newly diagnosed valvular disease have been traditionally excluded from de vice placement. The purpose of this study was to review our experience with LVAD support in patients with valvular disease and to develop a management algorithm for these difficult patients. Methods. We reviewed the clinical records of 199 consecutive patients who r eceived the ThermoCardiosystems, Inc, HeartMate Pneumatic or Vented Electri c LVAD. There were 18 patients (9%) who required surgical management of nat ive or prosthetic valvular disease during LVAD implantation. Results. Suture or patch closure of the aortic valve was performed in 6 pat ients, aortic valve plication and repair in 1 patient, mitral valve repair in 4 patients, and tricuspid valve annuloplasty in 5 patients. Two patients with mechanical mitral valve prostheses were treated with postoperative wa rfarin anticoagulation. Fifteen of the 18 patients with valvular pathology survived the immediate postoperative period (17% mortality). Eleven patient s have either undergone transplantation or continue to be supported with an LVAD (61%). Operative mortality in LVAD patients without concomitant valve repair was 18% (n = 33) with a late mortality of 7% (n = 13). Seven of the se late deaths occurred in patients who received a device as destination th erapy. In the remaining 6 patients, the cause of death was sepsis (n = 2), multisystem organ failure (n = 2), driveline rupture (n = 1), and massive g astrointestinal bleed (n = 1). Conclusions. Preexisting native or prosthetic valve pathology does not incr ease the immediate perioperative risk of LVAD insertion; however, these pat ients continue to pose a challenge for postoperative management while await ing transplantation. (Ann Thorac Surg 2001;71:1448-53) (C) 2001 by The Soci ety of Thoracic Surgeons.