New Challenges That We Are Facing LVAD Therapy for End-stage at Heart Failure

Surgical management for patients with end-stage at heart failure has been dramatically improved after clinical introduction of implantable LVAD. Although neurological event and driveline infection remain major complications after LVAD installation, new challenges for previously unpredicted complications have evolved. De novo aortic insufficiency (AI) has been highlighted as a significant issue that affect hemodynamic efficiency in a patient with LVAD support. Conventional transthoracic echocardiography fails to accurately assess the severity of AI due to unique features of LVAD-associated de novo AI. Several possible risk factors related to development of de novo AI have been addressed through multiple clinical analyses including lack of aortic valve opening and loss of pulsatile flow. Non-surgical management of patient condition and LVAD therapy are primarily recommended to prevent this devastating condition; however, surgical aortic valve closure or replacement can be reliable options for resolution of this entity. Secondly, acquired von Willebrand syndrome has also been recognized as an implantable LVAD-associated complication. Reduction of large multimer of con Willebrand factor is mediated by a cleavage enzyme of ADAMTS13, and the cleavage takes place when von Willebrand factor is exposed to high shear stress produced by high-speed rotary pump. Mechanism of gastrointestinal bleeding is at least in part attributable to acquired von Willebrand syndrome. Development of angiodysplasia is also suspected to be involved in the disease process.