Case Report:
A 59-year-old male patient with stage D congestive heart failure, NYHA class IV and severe right ventricular dysfunction with severe tricuspid regurgitation underwent Heartware ventricular assist device (HVAD) implantation and tricuspid valve annuloplasty. Due to the inability to maintain adequate Oxygenation, a right-sided ECMO was implanted allowing successful weaning from cardiopulmonary bypass. The immediate postoperative course was remarkable for the implantation of a temporary RVAD due to the inability to wean the patient from the right-sided ECMO. With gradual improvement of the right ventricular function, the RVAD could be removed approximately 1 month after its implantation. With further improvement of the patient´s condition in general and the right ventricular function in particular, the patient could be discharged home after 6 months postoperatively with a total hospital stay of approximately 9 months. 1 year later, the patient was readmitted with new-onset acute heart failure. Transthoracic echocardiography (TTE) revealed severe aortic regurgitation in both systolic and diastolic phases with substance defect in the non-coronary leaflet with volume overload of the left ventricle, VC 2 mm, and regurgitant jet width in LVOT of 6mm (> 25% of LVOT -diameter, 23mm), and severe right ventricular systolic dysfunction. In the LVAD-outflow graft from the right parasternal view a systolic velocity of 207 cm/s and a diastolic one of 129 cm/s with S/D-Ratio 1.6 (suggesting a hemodynamically relevant AI with a ratio < 5). Due to the patient’s high operative risk and the unfavorable anatomy a trial of medical treatment along with optimization of LVAD flow was attempted, but was unfortunately unsuccessful in improving the patient’s symptoms. Accordingly, the patient was listed as a candidate for urgent heart transplantation, and the operation was done successfully 7 months later. The patient was weaned from the ventilator on the 6thpostoperative day and was discharged home after approximately 3 months with post-operative transthoracic echocardiography revealing the normal systolic function of both ventricles.