18. AORTIC INSUFFICIENCY AND LATE RIGHT HEART FAILURE

18.1 Background
Under LVAD support, de novo aortic insufficiency can develop. The incidence varies in different publications from 10% [454] to 53% [384]. Recirculating blood will lead to systemic hypoperfusion of the patient. Additionally, incomplete unloading of the LV may lead to pulmonary artery hypertension compromising the RV function. Factors contributing to AR are fusion of the commissures and degenerative changes of the cusps caused by persistent aortic valve closure [455]. The diagnosis and the grade of regurgitation can be confirmed by echocardiography.

18.2 Evidence review
Factors that influenced AR development and progression were older age, persistent aortic valve closure, duration of LVAD support and female gender [456]. Treatment options include HTx, bioprosthetic valve replacement, patch closure or valve repairs. Transcatheter procedures have been shown to be effective for patients in whom the risk of reoperation is prohibitive [456–461].

18.3 Late right heart failure
Currently there is no established definition of late onset right ventricular failure (LORVF). Although in 2 studies LORVF was defined as the need for inotropic support or RVAD implantation starting 14 days after surgery, another study defined LORVF as a readmission requiring medical or surgical intervention [177, 468, 469].

18.4 Evidence review
In a large analysis of the INTERMACS database including 10 909 adult patients with primary LVAD support, the incidence of LORVF (>14 days) was 6.4% [468].
In a retrospective single-centre study including 336 patients, the incidence of LORVF was 11%. In these patients, diabetes mellitus, a body mass index >29 and blood urea nitrogen level >41 mg/dl were significant predictors of LORVF [469].
Diagnostic investigations of LORVF should include echocardiography and invasive haemodynamic measurements with a pulmonary artery catheter.