1 ASAIO Journal 2012 Development of aortic insufficiency (AI) in patients supported with continuous flow left ventricular assist devices (LVAD) can adversely affect pump performance. In this study, we examined the incidence of new AI after LVAD implant at our institution. Pre- and postoperative echocardiograms of 66 patients who received HeartMate II or Heartware LVAD at our institution since June 2008 were reviewed for presence of new AI. Median LVAD support duration was 221 days. New AI developed in 6 patients (9.5%) after a median time of 374.5 days of support. There were no cases of severe or symptomatic AI. There was no significant difference between the AI incidence between Heart- Mate II and Heartware recipients. For patients who remained on LVAD support at 6 and 12 months, freedom from AI was 100% and 68.4%, respectively. Age, destination therapy sta- tus, and duration of support were predictors of new AI after LVAD implant. In conclusion, AI develops frequently during long-term support with continuous flow LVADs, particularly in those supported for longer than 6 months. As we move to the era of long-term LVAD support and destination therapy, fur- ther studies with longer follow-ups are required to determine the progression and clinical significance of AI in these patients. ASAIO Journal 2012; 00:0–0. Continuous flow left ventricular assist devices (LVAD) are increasingly used to treat patients with end-stage left ven- tricular failure as bridge to transplantation and increasingly as destination therapy. 1,2 These new generation devices have the advantage of smaller size, increased device durability, and decreased incidence of adverse events. 3 However, the physi- ologic impact of long-term continuous, nonpulsatile flow is not fully understood. Specifically, the behavior of the native aortic valve in this setting is of particular interest. It is obvious that aortic insufficiency (AI) in the context of a continuous flow LVAD results in a circulatory loop where a portion of pump output returns through the incompetent aortic valve back into the pump, thus reducing effective forward flow. 4 Presence of significant AI at the time of LVAD implant is regarded as an indication for a concomitant procedure on the aortic valve to render it competent. 5 Similarly, development of significant de novo AI in LVAD supported patients may be an indication for subsequent intervention to improve pump efficiency. In this study, we sought to determine the prevalence and progression of new AI in patients implanted with continuous flow LVADs at our institution. We also sought to determine the risk factors for developing AI continuous-flow LVAD supported patients. Methods Echocardiograms (n = 195) of 66 consecutive patients who received HeartMate II (Thoratec, Pleasanton, CA) (HMII, n = 58) or Heartware (HeartWare Inc, Framingham, MA) (HW, n = 8) LVAD from June 2008 to October 2010 at our institution were retrospectively reviewed. Studies obtained within 1 month pre- operatively were considered as baseline. Postoperative echocar- diograms were reviewed at 3 monthly intervals. The degree of AI was graded as 0 = none, 1+ = mild, 2+ = mild-to-moderate, 3+ = moderate and 4+ = severe. AI was regarded significant if mild-to- moderate (2+) or greater. Patients with concomitant or previous aortic valve replacement (n = 2) or significant baseline AI (n = 1) were excluded from analysis. In addition to AI severity, aortic root diameter at baseline and opening of the aortic valve after implant were recorded. Baseline characteristics of the patients included in the study were obtained by systematic chart review. Statistical Analysis Categorical variables are presented as frequencies and per- centages and were analyzed using χ2 test. Continuous vari- ables are presented as means with standard deviations and were analyzed using Student’s I t-tests. Kaplan-Meier analysis was performed to demonstrate freedom from AI. In this analy- sis, censoring events were transplantation and death. Results Demographics Baseline characteristics of the cohort are depicted in Table 1. There were 55 patients with the HMII and eight patients with the HW device. There were 36 bridge-to-transplant and Development of Aortic Insufficiency in Patients Supported with Continuous Flow Left Ventricular Assist Devices BEHZAD SOLEIMANI, ANNICK HAOUZI, ANGELA MANOSKEY, EDWARD R. STEPHENSON, ALY EL-BANAYOSY, AND WALTER E. PAE Original Article From the Division of Cardiothoracic Surgery, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Penn State Hershey Heart & Vascular Institute, Hershey, Pennsylvania. Submitted for consideration November 2011; accepted for publica- tion in revised form February 2012. Disclosures: The authors have no conflicts of interest to report. Reprint Requests: Behzad Soleimani, MD, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Penn State Hershey Heart & Vascular Institute, Division of Cardiothoracic Surgery, Mail Code H165 500 University Drive, P.O. Box 850 Hershey, PA 17033-0850. Email: bsoleimani@hmc.psu.edu Copyright © 2012 by the American Society for Artificial Internal Organs DOI: 10.1097/MAT.0b013e318251cfff Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.