Transcatheter Aortic Valve Replacement as a Bridge to Left Ventricular Assist Device Implantation Adham Elmously, MD,* Berhane Worku, MD,* Evelyn M. Horn, MD,† Shing-Chiu Wong, MD,† and Arash Salemi, MD* Abstract: We describe a case of the pre-emptive use of transcatheter aortic valve replacement in a patient with end-stage ischemic cardiomyopathy and native aortic stenosis/aortic insufficiency as a bridge to left ventricular assist device implantation. The use of this strategy can not only medically op- timize patients before left ventricular assist device implantation but also provide a minimally invasive bridge to left ventricular assist device sup- port, avoiding concomitant surgical aortic valve replacement or closure. Key Words: Transcatheter aortic valve replacement, Circulatory support, Heart failure, Left ventricular assist device. (Innovations 2018;13:60–61) D e novo aortic insufficiency (AI) is a well-described entity after left ventricular assist device (LVAD) implantation. Management options include medical optimization with pump speed adjustment, and in more severe cases, surgical aortic valve repair, replacement, or closure. In more recent years, transcathe- ter aortic valve replacement (TAVR) has been described in this setting. 1 Given the known complications associated with de novo AI after LVAD placement, pre-existing AI mandates ag- gressive intervention at the time of LVAD implantation to pre- vent the known sequelae of malperfusion and heart failure. Conventional treatment involves concomitant AVR at the time of LVAD implantation, with the associated incremental risk, es- pecially in patients with greater preoperative comorbid status. 2 We therefore describe a case of the pre-emptive use of TAVR in a patient with end-stage ischemic cardiomyopathy and native AI/aortic stenosis (AS) as a bridge to LVAD implantation. CASE REPORT A 67-year-old man with a history of coronary artery disease status after coronary bypass grafting 15 years ago, subsequent percutaneous coronary intervention, ischemic cardiomyopathy with a baseline ejection fraction of 15% on home dobutamine, and severe AI was transferred to our center with a heart failure exacerbation for inotrope-assisted diuresis. Right heart catheterization demonstrated a pulmonary ar- tery systolic pressure of 70 mm Hg, a cardiac index of 1.6 L/min per square meter and a pulmonary artery saturation of 49%. A transthoracic echocardiogram (TTE) demonstrated severe AI and moderate to severe AS (mean gradient = 22 mm Hg, aortic valve area = 1.1 cm 2 ) with an ejection fraction of 8%. His con- dition did not improve despite aggressive medical management and LVAD implantation were recommended as a bridge to trans- plant. Surgical AVR was considered at the time of LVAD. How- ever, given the presence of AS, the risk of concomitant AVR at the time of LVAD was considered high given his Interagency Registry for Mechanically Assisted Circulatory Support score of 2. The decision was made to proceed with a TAVR before LVAD implantation. Contrast-enhanced multidetector computed to- mography was performed preoperatively, which demonstrated an annulus diameter of 27.6 mm by 22.6 mm, an area of 475 mm 2 , and a perimeter of 78.5 mm, measurements appropri- ate for a 26-mm SAPIEN valve. Transcatheter aortic valve replacement was performed in a hybrid cardiac catheterization laboratory under general anesthe- sia. Under fluoroscopic and transesophageal echocardiography guidance, a 26-mm SAPIEN III (Edwards Lifesciences Corp, Irvine, CA USA) valve was deployed via a transfemoral ap- proach (Fig. 1). Postdeployment transesophageal echocardiogra- phy demonstrated a well-functioning prosthesis with no evidence of paravalvular regurgitation. The patient clinically improved and was discharged home on postoperative day 3 with a plan for inter- val readmission and LVAD implantation. He was ambulating short distances with mild dyspnea. Follow-up TTE demon- strated a trace paravalvular leak and an ejection fraction of 12%. One month after TAVR, the patient underwent placement of a HeartMate II LVAD (Thoratec, Pleasanton, CA USA). His postoperative course was unremarkable, and he was discharged home on postoperative day 13. At the 6-month follow-up visit, the patient continued to have appropriate exercise tolerance, was New York Heart Association class II, and repeat TTE that demonstrated mild paravalvular regurgitation (Fig. 2). The pa- tient is currently doing well, awaiting heart transplant. DISCUSSION In patients with end-stage heart failure and AI, or in this case, AI and AS, who are in need of mechanical support, severe AI must be addressed at the time of LVAD implantation. Milder Accepted for publication November 28, 2017. From the Departments of *Cardiothoracic Surgery, and †Cardiology, New York Presbyterian Hospital – Weill Cornell Medicine, New York, NY USA. Disclosures: Shing-Chiu Wong, MD, serves as a proctor for Edwards Lifesciences Corp, Irvine, CA USA. Arash Salemi, MD, serves as a proctor for Edwards Lifesciences Corp, Irvine, CA USA, and Medtronic, Inc, Minneapolis, MN USA. Adham Elmously, MD, Berhane Worku, MD, and Evelyn M. Horn, MD, declare no conflicts of interest. Address correspondence and reprint requests to Adham Elmously, MD, Department of Cardiothoracic Surgery, New York Presbyterian Hospital – Weill Cornell Medicine, 1300 York Ave, Box 110, New York, NY 10065 USA. E-mail: ade9010@nyp.org. Copyright © 2018 by the International Society for Minimally Invasive Cardiothoracic Surgery ISSN: 1556-9845/18/1301–0060 CASE REPORT 60 Innovations • Volume 13, Number 1, January/February 2018 Copyright © 2018 by the International Society for Minimally Invasive Cardiothoracic Surgery. Unauthorized reproduction of this article is prohibited.