Stop the Leak! Transcatheter Aortic Valve Replacement in Pediatric VAD Patient

Abstract

Introduction Recognition of ventricular assist device (VAD) complications such as aortic insufficiency (AI) are important to optimize long-term management. We highlight a case of the treatment of severe AI in a pediatric continuous flow (CF) VAD patient using transcatheter aortic valve replacement (TAVR). Case Report A 9-year-old male with congenitally corrected transposition of the great arteries and pulmonary atresia underwent staged surgical palliation including a Mustard and Rastelli operation. He developed severe left ventricular (LV) dysfunction with refractory heart failure and underwent implant of a HeartWare (Medtronic, Minneapolis MN) in the morphologic LV on the right side at almost 5 years of age (weight 13.7 kg, BSA 0.64 m2). His waitlist time was prolonged due to significant allosensitization. After 4 years on support, clinical signs of congestive heart failure (CHF) developed and BNP rose (1000 pg/mL) despite optimal VAD performance. Cardiac catheterization showed severe AI and pulmonary hypertension. Mean pulmonary arterial pressure was 40 mmHg with pulmonary vascular resistance of 8.5 WUm2 that was responsive to pulmonary vasodilators. The pulmonary hypertension was attributed to the AI. To avoid a difficult redo sternotomy, TAVR was deemed the optimal way to replace his aortic valve. He underwent catheterization and a 29 mm Edwards SAPIEN 3 valve (Edwards Lifesciences, Irvine CA) was placed in the aortic valve position via right carotid artery cut down using a 21 French sheath. The VAD speed was reduced to 1800 RPM and rapid ventricular pacing allowed for stabilization during valve deployment. Post TAVR, angiography showed resolution of AI with only mild perivalvar leak around the aortic valve. After discharge, he was noted to have a transient rise in lactate dehydrogenase from baseline and increased bruising due to unclear etiology. Within 5 months of his TAVR, his diuretics were weaned with marked improvement in his BNP and resolution of his CHF. Summary AI is a significant complication of long-term CF VAD support that can lead to detrimental hemodynamics and worsening CHF. TAVR may be a reasonable therapy to mitigate AI in high-risk children.