title: Concomitant aortic valve procedures in patients undergoing implantation of continuous-flow left ventricular assist devices: An INTERMACS database analysis.
abstract: BACKGROUND
  Management of existing aortic insufficiency (AI) and mechanical aortic valves in patients undergoing left ventricular assist device (LVAD) implantation remains controversial. Surgical options to address these issues include closure, repair or replacement of the valve.
  
  
  METHODS
  Continuous-flow LVAD/biventricular VAD patients entered into the INTERMACS database between June 2006 and December 2012 were included (n = 5,344) in this analysis. Outcomes were compared between patients who underwent aortic valve (AV) closure (n = 125), repair (n = 95) and replacement (n = 85).
  
  
  RESULTS
  Among patients who underwent an AV procedure, actuarial survival was significantly reduced for AV closures (63.2%) compared with AV repairs (76.8%) and replacements (71.8%) (p = 0.0003). Differences were greater between groups when only INTERMACS Level 1 or 2 patients were analyzed (p = 0.003). After multivariate adjustment, AV closure remained a significant risk factor for mortality (hazard ratio = 1.87, 95% confidence interval 1.39 to 2.53, p < 0.0001). At 6 to 12 months post-operatively, moderate to severe AI developed in 19%, 5%, 9% and 10% of patients with available echocardiography who underwent repair, closure, replacement and no intervention, respectively (p < 0.0001). Competing outcomes demonstrate that, at 1-year, fewer patients with AV closures were transplanted compared with patients with repairs/replacements (14% vs 19%). No differences were observed between groups with respect to cause of death, re-hospitalization, right heart failure or stroke.
  
  
  CONCLUSIONS
  AV closure was associated with increased mortality when compared with repair or replacement in patients with AI who underwent LVAD insertion. The reasons for this association require further investigation. This is the largest study to date to examine concomitant AV procedures in patients undergoing LVAD insertion.
authors.affiliation: Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri.
authors.forename: Jason O
authors.initials: JO
authors.lastname: Robertson
authors.affiliation: Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama.
authors.forename: David C
authors.initials: DC
authors.lastname: Naftel
authors.affiliation: Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama.
authors.forename: Susan L
authors.initials: SL
authors.lastname: Myers
authors.affiliation: Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri.
authors.forename: Sunil
authors.initials: S
authors.lastname: Prasad
authors.affiliation: Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama.
authors.forename: Gail D
authors.initials: GD
authors.lastname: Mertz
authors.affiliation: Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri.
authors.forename: Akinobu
authors.initials: A
authors.lastname: Itoh
authors.affiliation: Cardiac Surgery Department, University of Michigan, Ann Arbor, Michigan.
authors.forename: Francis D
authors.initials: FD
authors.lastname: Pagani
authors.affiliation: Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama.
authors.forename: James K
authors.initials: JK
authors.lastname: Kirklin
authors.affiliation: Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri. Electronic address: silvestrys@wudosis.wustl.edu.
authors.forename: Scott C
authors.initials: SC
authors.lastname: Silvestry
mesh_terms: D000328:Adult; D000368:Aged; D001022:Aortic Valve Insufficiency / Q000453:epidemiology / Q000401:mortality* / Q000601:surgery*; D013504:Cardiovascular Surgical Procedures; D015897:Comorbidity; D016208:Databases, Factual; D005260:Female; D005500:Follow-Up Studies; D006353:Heart-Assist Devices; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D012042:Registries; D012189:Retrospective Studies; D015996:Survival Rate; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D018487:Ventricular Dysfunction, Left / Q000453:epidemiology / Q000401:mortality* / Q000601:surgery*
keywords: aortic valve; aortic valve closure; aortic valve repair; aortic valve replacement; left ventricular assist device