Anesthetic considerations for TAVR in a patient with HeartMate 3: A case report

Severe aortic insufficiency (AI) is associated with well-known pathophysiologic consequences related to onset acuity, with the possibility of pulmonary congestion and cardiogenic shock. The presence of AI in patients with continuous flow left ventricular assist device (LVAD) creates unique physiologic challenges due to recirculation of LVAD flow, rather than contributing to cardiac output. Correction of AI in patients with LVADs typically includes open surgical aortic valve replacement (SAVR). Prior sternotomy with resultant adhesions, as well as the presence of a mechanical circulatory support device, complicates surgical AVR and carries higher operative morbidity and mortality. While TAVR in patients with LVADs has been performed successfully, the procedure carries significant procedural risk related to retrograde valve embolization and potential disruption of LVAD inflow cannula. To date, there are no published studies outlining the optimal HeartMate 3 (HM3, Abbott, Chicago IL) LVAD parameters for valve deployment. This case report outlines HM3 flow, speed, and the pacing parameters used for successful deployment of a CoreValve Evolut Pro+ in a patient with severe AI.