Little has been known about management of recurrent AI after bioprosthetic AVR at the time of LVAD placement. A central coaptation stitch to these patients potentially is a good option for a bridge to transplant.
Short-term follow up in this patient shows promising results with only trace AI on echocardiogram. Although this technique has been shown to be a durable solution for patients with significant native aortic valve insufficiency , the long-term results of this technique especially in bioprosthetic valves remains to be seen to determine the durability of these results in the face of continued bioprosthetic valve degeneration.
Although there have been numerous studies of AI in LVAD patients, we don't know the long-term prognosis of patients who develops acquired AI. Since AI seemed to have negative impact on survival [1, 6], either bioprosthetic AVR or aortic valve repair is recommended for these patients. Patients with AI with following a previous bioprosthetic AVR, no recommendation is currently available. Performing a re-replacement bioprosthetic AVR may be more durable to prevent leaflet fusion, however explanting a previous valve and re-implant new valve in patients having an LVAD placement with concomitant severe RV dysfunction raises concerns about further impairing postoperative RV function. A Park's stitch to a bioprosthetic AVR is relatively easy, timely, safe and durable in LVAD patients being bridged to transplant.
This procedure was able to be performed in a quick and effective manner with short aortic cross clamp time to minimize the risk of RV dysfunction after LVAD placement.
The limitation of this technique in the setting of previous bioprosthetic AVR is no long-term mortality and morbidity data reported, therefore the application of this technique to destination patients should be cautious because of aortic valve leaflet fusion and potential thrombus formation below the fused aortic valve. If patients with AI from degenerating bioprosthetic AVR is listed as bridge to transplant, a Park's stitch to the bioprosthetic valve leaflets might be a good option to consider.
In conclusion, we reported a first successful case with Park's stitch and LVAD placement to previously placed bioprosthetic AVR. Further studies are mandatory to prove longevity and survival of this procedure in this context.