title: Surgical management of valvular disease in patients requiring left ventricular assist device support.
abstract: BACKGROUND
  Success with long-term implantable left ventricular assist devices (LVAD) has led to increased use in patients previously thought to be unsuitable for mechanical circulatory assistance. Patients with preexisting or newly diagnosed valvular disease have been traditionally excluded from device 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 received the ThermoCardiosystems, Inc, HeartMate Pneumatic or Vented Electric LVAD. There were 18 patients (9%) who required surgical management of native or prosthetic valvular disease during LVAD implantation.
  
  
  RESULTS
  Suture or patch closure of the aortic valve was performed in 6 patients, 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 warfarin anticoagulation. Fifteen of the 18 patients with valvular pathology survived the immediate postoperative period (17% mortality). Eleven patients 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 these late deaths occurred in patients who received a device as destination therapy. In the remaining 6 patients, the cause of death was sepsis (n = 2), multisystem organ failure (n = 2), driveline rupture (n = 1), and massive gastrointestinal bleed (n = 1).
  
  
  CONCLUSIONS
  Preexisting native or prosthetic valve pathology does not increase the immediate perioperative risk of LVAD insertion; however, these patients continue to pose a challenge for postoperative management while awaiting transplantation.
authors.affiliation: Department of Cardiothoracic Surgery, New York Presbyterian Hospital, College of Physicians and Surgeons, Columbia University, New York 10032, USA.
authors.forename: V
authors.initials: V
authors.lastname: Rao
authors.forename: J P
authors.initials: JP
authors.lastname: Slater
authors.forename: N M
authors.initials: NM
authors.lastname: Edwards
authors.forename: Y
authors.initials: Y
authors.lastname: Naka
authors.forename: M C
authors.initials: MC
authors.lastname: Oz
mesh_terms: D000328:Adult; D000368:Aged; D000465:Algorithms; D001021:Aortic Valve / Q000601:surgery; D002423:Cause of Death; D005260:Female; D006349:Heart Valve Diseases / Q000401:mortality / Q000601:surgery*; D019918:Heart Valve Prosthesis Implantation; D006353:Heart-Assist Devices; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000601:surgery; D011183:Postoperative Complications / Q000401:mortality; D012086:Reoperation; D014261:Tricuspid Valve / Q000601:surgery