Transcatheter aortic valve replacement for aortic insufficiency in a patient with aortic root Thrombus and left ventricular assist device: A risk worth taking?

A 61-year-old man with end-stage ischemic cardiomyopathy post HeartMate 3 (Abbott laboratories, Chicago, Illinois, USA) left ventricular assist device (LVAD) implant was hospitalized after he had recurrent ventricular tachycardia requiring implantable cardioverter-defibrillator shocks. His transthoracic echocardiogram and computed tomography angiography of the chest showed presence of trace aortic insufficiency (AI) and aortic root thrombus (ART) of non-coronary cusp without obstruction of right or left coronary artery ostium despite therapeutic international normalized ratio. He presented again 3 months later with worsening heart failure signs and symptoms. Transesophageal echocardiogram showed progression to severe AI and persistent ART. Despite hemodynamically guided LVAD speed optimization, inotropic support, and diuresis, the patient continued to deteriorate with worsening renal function. The patient was not a transplant candidate due to frailty. After multi-disciplinary discussion he underwent successful 29-Sapien S3 (Edwards Lifesciences, Irvine, CA, USA) transcatheter aortic valve replacement utilizing distal protection filters in bilateral internal carotid arteries for stroke prevention. This case provides novel insight to physicians treating LVAD patients regarding management of severe AI in the setting of ART. LEARNING OBJECTIVE: We report a rare approach employed for management of aortic insufficiency (AI) in a patient who also had an aortic root thrombus and left ventricular assist device (LVAD) that traditionally requires cardiac transplantation. Our patient had a favorable outcome with a minimally invasive transcatheter aortic valve replacement. With this case, we hope to generate awareness amongst physicians treating patients about management alternatives and approach of a commonly encountered, life-threatening complication of AI in patients with LVAD.