The Development and Clinical Impact of Aortic Regurgitation Following Left Ventricular Assist Device Surgery: An Analysis of the IMACS Database

Purpose We aimed to investigate the determinants and clinical impact of dynamic moderate-to-severe (mod-sev) aortic regurgitation (AR) on the long-term outcomes following LVAD implantation. Methods The international multicenter registry data from the International Society of Heart and Lung Transplantation Mechanically Assisted Circulation Support (IMACS) registry was used. All adult LVAD patients, implanted between January 2013 until September 2017, with at least 1 echocardiogram available following implantation were included. Longitudinal evolution of AR was modeled using logistic mixed effect models. Joint modelling was used to link the dynamic longitudinal evolution of AR to a relative risk model for morality (Cox). Outcomes are presented by hazard ratios and two simulated Kaplan Meier curves presenting two identical patients. Results In total, 12.810 patients (median age 58 [48-66], 78.5% male) were included, with 36.343 echocardiograms available. Following LVAD implantation, mod-sev AR was observed in 1.660 (12.9%) patients on 2.660 different echocardiograms. The strongest predictors for the development of mod-sev AR included mild AR at baseline and prolonged LVAD support. Moreover, concomitant aortic valve replacement, opposed to repair surgery, was associated with a substantial lower risk for the development of mod-sev AR. Both the presence of mod-sev AR, as the pace of the probability of AR was changing (slope), were significantly associated with increased mortality. Survival following the development significant AR is heavily impacted, as displayed in Figure 1. Conclusion The development of significant AR occurs approximately in 1 in 8 patients following LVAD implantation. Subsequent mortality seems largely dictated by the pace of the development of mod-sev AR, with a faster development of AR being associated with less favorable outcomes.