Transesophageal echocardiographic guidance of transcatheter closure of the aortic valve in a patient with left ventricular assist device-related severe aortic regurgitation

A 68 year-old man with a severe ischemic cardiomyopathy underwent left ventricular assist device (LVAD) implantation (Heart Mate II device) for destination therapy. He presented 49 months following LVAD implant with worsening heart failure symptoms and new severe aortic regurgitation. Given high risk for both surgical and transcatheter aortic valve replacement, he was admitted for transcatheter closure of the aortic valve under transesophageal echocardiographic (TEE) guidance. TEE imaging revealed severe aortic regurgitation (see Figure 1A and 1B, and multimedia files 1 and 2). Under TEE and fluoroscopic guidance, a 25 mm Amplatzer cribiform atrial septal defect closure device was advanced across the aortic valve (see figures 1C and 1D, and multimedia files 3 and 4). Immediately following device deployment, TEE revealed a well-seated device with complete aortic valve closure, and trivial aortic regurgitation (see figures 2A-D, and multimedia files 5-7). Subsequent transthoracic echocardiograms obtained from 74 to 172 days post-procedure revealed no residual aortic regurgitation. The patient awoke with diffuse urticaria 244 days following the procedure, and died en route to the emergency department, presumably secondary to a systemic allergic reaction. De novo aortic regurgitation is increasingly recognized in patients with LVADs (1). TEE guided transcatheter aortic valve closure is an option in these high-risk patients (2).