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\begin{document}

\title{Redo Heart transplantation in a high-risk patient due to severe aortic
regurgitation and accompanying right ventricular failure after LVAD
implantation and temporary RVAD support}



\author[1]{Muhammad Arab R}%
\author[1]{Yeong-Hoon Choi}%
\author[1]{Oliver Liakopoulos}%
\author[1]{Mohamed Zeriouh}%
\affil[1]{Kerckhoff-Klinik GmbH}%


\vspace{-1em}



  
  \date{June 09, 2024}


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\selectlanguage{english}
\begin{abstract}
\textbf{Abstract} \textbf{Background:} We report a 62-year-old patient
who received redo-orthotopic Heart transplantation due to worsening
severe aortic regurgitation after 19 months of continuous flow LVAD
(cf-LVAD) and temporary RVAD support for one month. \textbf{Case
Report:} The patient received a heartware LVAD (HVAD) and annuloplasty
of the tricuspid valve due to end-stage heart failure (as a consequence
of dilated cardiomyopathy) and severe tricuspid regurgitation in
addition to right-sided ECMO implantation. Postoperatively due to the
inability to wean the implanted ECMO, a temporary RVAD was implanted
after which the patient's condition improved so that it had been
explanted later and the patient was discharged after nine-month. In
immediate post-operative echo, minimal aortic regurgitation was noted
but in the follow-up transthoracic echocardiograms, there was a gradual
increase in the severity of aortic regurgitation with worsening both
right and left ventricular functions. TAVI was not an option due to
unfavourable anatomical issues. That's why the patient was listed for
urgent heart transplantation, performed 19 months after the LVAD
implantation. The postoperative course was complicated due to acute
renal failure. After recompensation, dialysis, and intensive
physiotherapy, the patient could be discharged home after three months.
\textbf{Conclusion:} severe aortic regurgitation is a recognizable
complication after cf-LVAD implantation which in our case was managed
successfully with orthotopic heart transplantation in this high-risk
patient.%
\end{abstract}%



\sloppy


Redo Heart transplantation in a high-risk patient due to severe aortic
regurgitation and accompanying right ventricular failure after LVAD
implantation and temporary RVAD support

Muhammad R Arab\textsuperscript{1}, Yeong-Hoon Choi\textsuperscript{2},
Oliver J.~Liakopoulos\textsuperscript{3},~Mohamed
Zeriouh\textsuperscript{4}

\textsuperscript{1}Department of Cardiac surgery, Kerckhoff-Klinik GmbH,
Bad Nauheim, University Giessen, Germany

\textsuperscript{2}Department of Cardiac surgery, Kerckhoff-Klinik GmbH,
Bad Nauheim, University Giessen, Germany

\textsuperscript{3}Department of Cardiac surgery, Kerckhoff-Klinik GmbH,
Bad Nauheim, University Giessen, Germany

\textsuperscript{4}Department of Cardiac surgery, Kerckhoff-Klinik GmbH,
Bad Nauheim, University Giessen, Germany

\textbf{Corresponding Author's information:} Muhammad Refaat Arab, Bad
Nauheim,

muhammadr.arab@yahoo.com.

Department of Cardiac Surgery, Kerckhoff-Klinik GmbH, University Giessen

No financial disclosures.

No conflicts of interest.



\textbf{Abstract}

\textbf{Background:} We report a 62-year-old patient who received
redo-orthotopic Heart transplantation due to worsening severe aortic
regurgitation after 19 months of continuous flow LVAD (cf-LVAD) and
temporary RVAD support for one month.

\textbf{Case Report:} The patient received a heartware LVAD (HVAD) and
annuloplasty of the tricuspid valve due to end-stage heart failure (as a
consequence of dilated cardiomyopathy) and severe tricuspid
regurgitation in addition to right-sided ECMO implantation.
Postoperatively due to the inability to wean the implanted ECMO, a
temporary RVAD was implanted after which the patient's condition
improved so that it had been explanted later and the patient was
discharged after nine-month. In immediate post-operative echo, minimal
aortic regurgitation was noted but in the follow-up transthoracic
echocardiograms, there was a gradual increase in the severity of aortic
regurgitation with worsening both right and left ventricular functions.
TAVI was not an option due to unfavourable anatomical issues. That's why
the patient was listed for urgent heart transplantation, performed 19
months after the LVAD implantation. The postoperative course was
complicated due to acute renal failure. After recompensation, dialysis,
and intensive physiotherapy, the patient could be discharged home after
three months.

\textbf{Conclusion:} severe aortic regurgitation is a recognizable
complication after cf-LVAD implantation which in our case was managed
successfully with orthotopic heart transplantation in this high-risk
patient.

\textbf{Keywords:} aortic regurgitation, LVAD, heart transplantation,
right ventricle failure

\textbf{Background:}

Aortic regurgitation developing after continuous flow LVAD (cf-LVAD)
implantation is not uncommon and represents an eminent problem that can
affect LVAD performance {[}1{]}. Currently, it is not known if the
progression of aortic insufficiency (AI) differs with different LVAD
models or with pump hemodynamics {[}1{]}. With increasing severity of
AI, a vicious circle develops, whereby most of the pumped blood through
the outflow graft regurgitates back into the left ventricle leading to
ineffective LVAD function and worsening heart failure symptoms and signs
{[}1{]}. Predictors of severe AI in our Patient included Age
\textgreater{} 60 years, chronic kidney disease, LVEDD \textgreater{}
6.8 cm, and PCWP\textgreater{} 18 mmHg. Here, we present a case of a
patient who received a heart transplant due to heart failure with
hypoperfusion symptoms secondary to severe aortic regurgitation.

\textbf{Case Report:}

A 59-year-old male patient with stage D congestive heart failure, NYHA
class IV and severe right ventricular dysfunction with severe tricuspid
regurgitation underwent Heartware ventricular assist device (HVAD)
implantation and tricuspid valve annuloplasty. Due to the inability to
maintain adequate Oxygenation, a right-sided ECMO was implanted allowing
successful weaning from cardiopulmonary bypass. The immediate
postoperative course was remarkable for the implantation of a temporary
RVAD due to the inability to wean the patient from the right-sided ECMO.
With gradual improvement of the right ventricular function, the RVAD
could be removed approximately 1 month after its implantation. With
further improvement of the patient\selectlanguage{ngerman}´s condition in general and the right
ventricular function in particular, the patient could be discharged home
after 6 months postoperatively with a total hospital stay of
approximately 9 months. 1 year later, the patient was readmitted with
new-onset acute heart failure. Transthoracic echocardiography (TTE)
revealed severe aortic regurgitation in both systolic and diastolic
phases with substance defect in the non-coronary leaflet with volume
overload of the left ventricle, VC 2 mm, and regurgitant jet width in
LVOT of 6mm (\textgreater{} 25\% of LVOT -diameter, 23mm), and severe
right ventricular systolic dysfunction. In the LVAD-outflow graft from
the right parasternal view a systolic velocity of 207 cm/s and a
diastolic one of 129 cm/s with S/D-Ratio 1.6 (suggesting a
hemodynamically relevant AI with a ratio \textless{} 5). Due to the
patient's high operative risk and the unfavorable anatomy a trial of
medical treatment along with optimization of LVAD flow was attempted,
but was unfortunately unsuccessful in improving the patient's symptoms.
Accordingly, the patient was listed as a candidate for urgent heart
transplantation, and the operation was done successfully 7 months later.
The patient was weaned from the ventilator on the
6\textsuperscript{th}postoperative day and was discharged home after
approximately 3 months with post-operative transthoracic
echocardiography revealing the normal systolic function of both
ventricles.

\textbf{Discussion:}

Secondary aortic regurgitation is a recognizable complication occurring
after cf-LVAD implantation {[}2{]}. Severe enough, it can affect the
hemodynamic performance of the LVAD manifesting with signs of end-organ
hypoperfusion. Combined with right ventricular insufficiency, less
invasive therapeutic options like TAVI seemed adequate but were not
possible, and although high risk, the patient was listed for urgent
heart transplantation which took place a few months later. The operative
and postoperative course was unremarkable with gradual recovery of
kidney function and marked improvement of patient symptoms.

\textbf{Conclusion:}

In our case, we have demonstrated that heart transplantation although
more invasive and associated with a very high peri-operative mortality
was a feasible option in our high-risk patient.

\textbf{References:}

{[}1{]} Cowger J, Pagani F D, Haft J W, Romano M A, Aaronson K D, Kolias
T J. The development of aortic insufficiency in left ventricular assist
device-supported patients.~\emph{Circ Heart Fail.~} 2010;3(06):668--674.

{[}2{]} Pak S W, Uriel N, Takayama H, et al. Prevalence of de novo
aortic insufficiency during long-term support with left ventricular
assist devices.~\emph{J Heart Lung Transplant.~} 2010;29(10):1172--1176.

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