**7. Prevention and treatment of AI in LVAD patients**

The goals for AI management are to treat the symptoms, lower long-term consequences, and improve patient outcomes [64]. Patients with mild-moderate AI and normal aortic root size, or asymptomatic severe AI and regular LV size/function are usually managed with vasodilators [65], although many debates the effectiveness in delaying AV repair or replacement [64, 66]. Meanwhile, patients with symptomatic severe AI, asymptomatic severe AI, and systolic dysfunction/LV dilation require surgical management [67, 68]. Mild-moderate AI is often corrected at the time of LVAD implantation, especially in long-term supported patients, or in those with larger body sizes and large aortic root diameters (>3.3 cm) [6, 23, 69].

Surgical treatment is selected based on the candidate's underlying pathology, LVAD support duration, and INTERMACS classification to allow the possibility of LV recovery by maintaining the native AV structure and function (**Figure 11**) [6, 69–71]. Without any repair procedure, pre-existing mild AI is three times more likely to progress to moderate-severe AI [23]. Other complications worsen in the long term, including right ventricle dysfunction, mitral and tricuspid regurgitations [24].

#### **7.1 Partial closure central park stitch/modified park stitch**

The Park Stitch includes a single, pledgeted 4–0 Prolene suture placed at the central portion of the AV leaflets [70]. It is effective when the original valvular tissue is sufficiently thick and has enough tensile strength to hold the sutures. Alternatively, the modified Park stitch, consisting of stitches securing pledgets with individual commissural at the AV center, is recommended when the valve leaflets are relatively thin [72]. The recipients are monitored carefully during LVAD speed regulation and ramp testing to avoid stitch rupture from sudden AV opening [18]. These techniques have debatable durability: at 4–6 months post-implant, approximately 20% moderate-worse AI recurrence rate occurred in some centers [69, 73], while others reported a much lower rate (0 to 7%) [6, 72].

*Aortic Insufficiency in LVAD Patients DOI: http://dx.doi.org/10.5772/intechopen.106173*

**Figure 11.**

*Summary of the current treatment guidelines for pre-existing AI at the time of LVAD implant [6, 69–71].*
