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Purpose Left ventricular assist device (LVAD) has been reported to improve pulmonary hypertension (PH) due to left heart disease (PH-LHD). However, prevalence of combined post- and pre-capillary PH (Cpc-PH) in patients with PH-LHD and the impact of LVAD implantation on Cpc-PH has not been fully elucidated. This study aimed to investigate hemodynamic changes following LVAD implantation in patients with PH-LHD to assess pulmonary vascular reverse remodeling. Methods Eighty-nine patients with advanced heart failure complicated by PH-LHD undergoing LVAD implantation who received serial right heart catheterizations at least 3 time points (before, early after, and 1-year after implantation) were retrospectively reviewed. Patients were divided into 2 groups as Cpc-PH group (n=50): pulmonary vascular resistance (PVR) > 3 Wood unit (WU) or diastolic pulmonary pressure gradient (DPG) ≥ 7 mmHg, and isolated post-capillary PH (Ipc-PH) group (n=39). Results Values of brain natriuretic peptide and transaminase in Cpc-PH group were higher than those in Ipc-PH group. Cpc-PH patients were consisted of 41 with PVR > 3 WU, 8 with PVR > 3 WU and DPG ≥ 7 mmHg, and 1 with DPG ≥ 7 mmHg preoperatively. Median values of PVR in both groups significantly decreased early after LVAD implantation [from 4.1 to 2.7 WU (p 3 WU (n=14) or DPG ≥ 7 mmHg (n=1) at that point. Among these 15 patients, 4 patients still remained on their PVR > 3 WU (n=3) or DPG ≥ 7 mmHg (n=1) even 1-year after LVAD implantation. PVR and DPG in these 4 patients turned to normal values at 3-year after implantation. Conclusion Over half of patients with PH-LHD were complicated by Cpc-PH in our study cohort. LVAD implantation readily improved hemodynamics regardless of complication of Cpc-PH, whereas 15 patients were still found to be PVR > 3 WU or DPG ≥ 7 mmHg which should be considered as persistent Cpc-PH. We speculate that most of Cpc-PH in patients with PH-LHD might be caused by alteration of vascular tone which will be promptly relieved by substantial left ventricular unload, however a certain number of patients with Cpc-PH might develop structural remodeling of pulmonary vasculature which requires months or years to achieve pulmonary vascular reverse remodeling.

Purpose Endomyocardial biopsy (EMB) is a gold standard to detect acute cellar cardiac rejection (ACR), but due to its invasiveness, a new non-invasive approach is warranted. Our final goal is to identify new biomarkers corresponding to ACR severity. Using RNA-seq analysis, we found specific gene expression profiles in EMB specimens corresponding to the grades of ISHLT criteria. We also established a transcriptome analysis method utilizing an FFPE (formalin fixed paraffin embedded) EMB section remained after pathological examination. Methods 1. Gene expression profiling in fresh frozen EMB section: 7 cardiac recipients who had pathological ACR were enrolled. They were divided into two groups: patients with before and at rejection ISHLT grade 1A (G-going; N=3) and with at and after treating rejection grade 1A (G-resolving; N=4). Transcriptome analysis was performed using a fresh frozen section (0.5 - 3 mm wide, 7 µm thickness). 2. Establishment of a 3’mRNA-seq method utilizing thin FFPE EMB section: 28 myocardial specimens (grade 0 in 7, 1A in 12, 2 in 2, 3A in 4 and quilty in 3) were analyzed. 3’mRNA-seq libraries were prepared using total RNA isolated from an FFPE section (1-2 mm wide, 5 µm) remained after pathological examination. 3. GSEA (Gene Set Enrichment Analysis) and DGE analysis: After RNA-sequencing, gene expression profiling was analyzed by GSEA and clustered by k-means. Results In G-going, we identified up-regulation of the genes mainly related to ACR, interferon gamma, inflammation, and ILG-JAK-STAT3 signaling, while in G-resolving, we identified down-regulation of these genes. Inflammatory responses were also observed in 3’mRNA-seq analysis using FFPE section. We also separated 270 up-regulating genes in grade3A and 229 ACR related genes associated with ISHLT criteria. In our analysis, most of these identified genes were not listed in AlloMap ®. Conclusion Although these analyses were preliminary because of the 1st analysis stage, these technique for analyzing gene expressions using a tiny myocardial sample may have a role to find new biomarkers associated with ACR.

Purpose An extracorporeal centrifugal-flow left ventricular assist device (CF-E-LVAD) system (BR16010) was newly developed. Since implantation of the durable implantable LVAD (I-LVAD) is still controversial in patients with cardiogenic shock or refractory heart failure because of its significant inferiority of outcomes as compared with higher INTERMACS profile patients, short-term E-LVADs have been still clinically important for bridging strategy for the next definitive treatment. Our aim of this study was to evaluate the influence of the novel developed CF-E-LVAD on the clinical prognosis in patients with bridging strategy, as compared with conventional extracorporeal pulsatile flow LVAD (PF-E-LVAD). Methods We retrospectively reviewed the medical records of 62 patients who were implanted E-LVAD as bridging strategy from April 2011 to January 2019. Six patients (9.7%) were implanted CF-E-LVAD. The clinical prognosis until 30 days after E-LVAD implantation, and the change of cardiac function and laboratory data at the early follow up were evaluated. Results Improvement of left ventricular ejection fraction was significantly greater in the CF-E-LVAD group than in the PF-E-LVAD group (217.9 [147.8 to 335.3] vs 38.3 [-21.7 to 128.8] %, P=0.010). Serum total bilirubin level significantly improved in CF-E-LVAD group than in the PF-E-LVAD group (-7.9 [-33.3 to 82.4] vs 68.8 [10.0 to 202.1] %, P=0.041). Although clinical courses, including death, cerebrovascular accidents and re-thoracotomy due to removal of mediastinal hematoma, were no significant difference between two groups, almost half (54.5%) in the PF-E-LVAD group was still ongoing the E-LVAD support at the 30 days post-E-LVAD implantation while only one patient (16.7%) was supported with E-LVAD in the CF-E-LVAD group. Conclusion The novel developed CF-E-LVAD system might influence on the earlier recovery of cardiac function and the multiple organ failure, and lead to the earlier decision for next definitive strategy.

Purpose Central extracorporeal life support (ECLS) has been shown to yield a sufficient flow support with unloading of heart and lung in cases having acute refractory heart failure with durable LVAD candidacy being uncertain. In contrast, subsequent implantation of durable LVAD after the bridge by the central ECLS is reportedly associated with morbidities in-hospital and long-term. This study aimed to review outcomes of this bridge strategy from central ECLS to durable LVAD, as compared to those of primary LVAD implantation. Methods This study enrolled an institutional consecutive series of 158 cases who underwent durable LVAD implantation from April 2013 to September 2020. Of these, 43 cases (27%), who were bridged from central ECLS, were compared with 115 cases (73%) who underwent primary durable LVAD implantation. Results The mean age was 45.2±12.2 years and 111 cases were male. Durable LVAD included HeartMateII 120 cases, HeartMate3 in 38 cases. Before the durable LVAD implantation, there were significant intergroup differences in systolic diameter of the LV (Bridge; 51.7±2.0 vs Primary; 65.0±1.2 mm, p Conclusion The bridge strategy yielded similar midterm outcomes as compared to the primary strategy, apart from stroke incidence which was more prominent after the bridge strategy. Perioperative care for bleeding potentials may protect from stroke after the bridge strategy.

Purpose Heparin-induced thrombocytopenia (HIT) is an immune-mediated condition associated with thrombocytopenia and thrombotic complications. The condition is increasingly recognized in hospitalized patients including severely injured trauma patients. Because these patients may eventually be considered for organ donation, management of the HIT screen positive donor has become an important issue in transplant surgery. We describe the recent management of 2 cardiac allograft donors with HIT. Methods At organ recovery, both male adult donors were hemodynamically stable with a normal appearing heart and no evidence of thrombosis. The donor underwent a routine multiple organ allograft recovery with argatroban infused over 15 minutes immediately before aortic cross-clamping after confirming activated clotting time (ACT) of greater than 400 sec. The cardiac allograft was flushed in the donor operating room with a total of 4 liters of cold Celsior solution. These hearts were transplanted in patients with dilated cardiomyopathy and cardiac sarcoidosis by modified bicaval anastomosis technique using heparin for anticoagulation therapy during cardiopulmonary support. Both were bridged with implantable left ventricular assist device (Heart Mate II and Jarvik 2000, respectively). Results This management strategy resulted in successful multiple organ transplants (Case 1: heart, two single lungs, liver, 2 kidney, case 2: heart, bilateral lung, liver, pancreas, 2 kidneys). Neither of the heart and other recipients demonstrated signs or symptoms of HIT, or neither had any postoperative thrombotic complications.. Conclusion Based on this experience, a treatment algorithm for managing HIT donors using argatroban is proposed for heart donors as well as other organ donors

Purpose Mechanical circulatory support for acute biventricular failure is challenging. Given that durable VAD is available only for LV support as bridge-to-transplantation in Japan, the treatment options for this pathology are limited to extracorporeal biventricular assist device (BiVAD) support first, which can be subsequently upgraded to durable LVAD in cases having recovery of RV function and transplant candidacy. The purpose of this study was to review the outcomes of extracorporeal BiVAD and to explore factors associated with the outcomes. Methods This study enrolled an institutional consecutive series of 39 cases who underwent extracorporeal BiVADs implantation for acute biventricular failure between April 2014 and October 2020. The etiological diagnosis was myocarditis in 27 cases, acute MI in 6 cases, and dilated cardiomyopathy (DCM) in 6 cases. The cases were assigned into the two groups according to the BiVAD support less than 7 days (n=18, Short group) or 7 days or more (n=21, Long group). The Long group consisted of 6 cases of acute MI (100%), 13 cases (48%) of myocarditis, two cases of DCM (33%). Results There was no case who deceased within 7 days after BiVAD implantation. In the Short group, extracorporeal LVAD was weaned-off in 11 cases (61%) or upgraded to durable LVAD in 6 cases after withdrawal of RV support within 7 days. The remaining one case deceased under extracorporeal LVAD. In the Long group, RV support was discontinued in 10 cases in the median support of 60 days (IQR; 24.2-76.8), while two cases were on BiVAD support at October 2020. The remaining nine cases (43%) deceased under BiVAD support in-hospital. Survival and VAD-free survival at 1 year were 79% and 56% in the Short group versus 48% and 20% in the Long group, respectively. Conclusion Outcomes of extracorporeal BiVAD support for acute biventricular failure were dependent on recovery of RV function. Targeting approach for RV function would be warranted for poor biventricular function.

Purpose Everolimus (EVL) can be utilized after heart reduce calcineurin inhibitor (CNI) associated nephrotoxicity, due to cell cycle inhibitor adverse effects, and as adjunct therapy for rejection and cardiac allograft vasculopathy (TCAV). Since 2007, we have primarily considered converting from mycophenolate mofetil with standard-dose CNIs to EVL with low-dose CNIs for the following recipients: 1) recipients with impaired renal function; 2) those with increases in or an initially large maximal intimal thickness (MIT) on routine intravascular ultrasound (IVUS) examinations; 3) donor derived TCAV; and 4) those with MMF-related leukopenia. In the present study, mid-term safety and effectiveness of EVL on heart transplant recipients with renal dysfunction or TCAV. Methods A single-center, retrospective cohort study was conducted including 116 adult heart transplant patients between 1999 and 2018. Sixty nine of 116 patients was started EVL and patients who was initiated EVL due to renal dysfunction (n=21) with longer than 1 year follow-up of serum creatine and TCAV (n=22) with longer than 3 years follow-up of annual MIT measurement by IVUS were enrolled in this study. The trough levels of EVL were evaluated at 1 week after initiation. Once target trough levels of EVL (6-8 ng/mL) were achieved, the CNI dose was reduced to obtain target trough levels. EVL efficacy on renal dysfunction and TCAV and safety were assessed. Results In 21 patients given EVL due to renal dysfunction, serum creatinine was significantly decreased from initiation of EVL to 1 year after initiation (1.44 +/- 0.32 vs 1.23 +/- 0.36 mg/dL; p=0.0004), but that did not significantly changed since then. In 22 patients given EVL due to TCAV, MIT was significantly decreased from initiation of EVL to 3 years after initiation (1.20 +/- 0.38 mm vs 1.00 +/- 0.40 mm, p Conclusion EVL with low-dose CNI might play a role in short-term improvement in renal function and TCAV in heart transplant patients. However, immunosuppressive regimen to furtherly improve renal function or TCAV mid-term after initiation of EVL should be investigated.

Purpose Driveline infection (DLI) is one of the major complications after durable VAD implantation. Since 2016, we have changed from the standard method to a double-tunnel method for driveline (DL) derivation, in which DL was once led to the upper right abdomen, then passed through the subcutaneous tissue horizontally to the left upper abdomen. This study aimed to verify the therapeutic efficacy of the double tunnel method on DLI. Methods From April 2013 to January 2019, all 120 cases of HeartMate2(HM2) implanted for BTT at our hospital were divided into 2 groups; 38 cases for whom DL exited directly from the upper right abdomen (S group) or 82 cases of the double tunnel method (D group). There was no significant intergroup difference in age (41 vs 46; P = 0.05), male ratio 79% vs 67%, (p = 0.2), or BTB case (16% vs 31%, P = 0.1). Results DLI occurred in 12 cases (32%) in the S group and 14 cases (17%) in the D group (P = 0.1). The interval between the HM2 implantation and the first DLI occurrence was not significantly different (585 vs 414 days, P = 0.2). Treatment of the DLI was more conservative in the S group, where surgical DL translocation (DTL) was performed in 1 case (8%) in the S group and 10 cases (71%) in the D group (P l0.01). The DTL resulted in primary cure 1 case of the S group (100%) and 8 cases of the D group (80%). The 2 cases who failed to show primary cure post-DTL underwent pump exchange. The medical therapy and/or local irrigation was selected as the primary treatment of DLI in 8 cases of the S group (67%) and in 4 cases of the D group (29%) As a result, 1 case of the S group and 1 case of the D group showed the primary cure, whereas the remaining 10 cases (83%) continued daily wound care and intravenous antibiotics in hospital. Conclusion DLI occurred one year or more after durable VAD implantation on average, regardless of the driveline derivation method. The double tunnel method contributed to opening the window for aggressive surgical treatment which more frequently resulted in a primary cure of the DLI than the conservative therapy.

Purpose Cardiac allograft vasculopathy (CAV) is still a major cause of mortality in heart transplant (HTx) recipients. Risk stratification for predicting the development of CAV is needed to suppress the development of CAV. Our aim of this study is to clarify the risk factors for the development of CAV. Methods We retrospectively reviewed consecutive 100 HTx recipients who did not have any coronary artery lesions on first coronary angiography at 5 to 12 weeks after transplantation (baseline). Donor-transmitted atherosclerosis (DA) on intravascular ultrasound (IVUS) was defined as a maximal intimal thickness of 0.5 mm or greater at baseline. Pathology diagnosis of cardiac antibody-mediated rejection (pAMR) was pathologically diagnosed on the basis of the 2013 ISHLT working formulation. The development of CAV included the any coronary revascularization, acute myocardial infarction and the coronary artery lesions classified ISHLT CAV 1 or 2. Results DA on IVUS was observed in 62 recipients regardless of no apparent lesions on angiography. pAMR was diagnosed in six recipients within 1year post-HTx. Sixteen recipients had the development of CAV, including five who underwent revascularization, one who had acute myocardial infarction and three who found the moderate lesions classified ISHLT CAV2. DA and the occurrence of pAMR within 1 year post-HTx significantly influenced on the cumulative incidence of development of CAV at a mean follow up period of 6.7±4.6 years after transplantation [Hazard ratio (HR): 5.2, 95% confidence intervals (CI):1.2-23.0, P=0.029 and HR: 7.3, 95% CI:2.0-26.7, P=0.003, respectively]. Multivariable cox proportional hazard model including DA, the occurrence of pAMR and associated variables with the development of CAV showed that DA and the occurrence of pAMR were independently associated with the development of CAV (HR: 5.4, 95%CI:1.2-24.6, P=0.028 and HR: 6.7, 95%CI:1.5-29.1, P=0.012, respectively). Conclusion DA and the occurrence of pAMR within 1 year post-HTx independently influenced on the development of CAV.

Purpose Continuous flow left ventricular device (CF-LVAD) brings a substantial survival improvement in end-staged heart failure patients. However, bleeding complications are common after CF-LVAD implantation, and in some cases a re-exploration for bleedings is needed. We investigated the incidence, timing and risk factors for a re-exploration for bleedings after CF-LVAD implantation. Methods we retrospectively reviewed 162 consecutive patients (age 43 ± 13 years, 71% men) who underwent CF-LVAD implantation (HeartMateII 119, Jarvik2000 15, HVAD 13, EVAHEART 10, DuraHeart 5) in our center from January 2012 to June 2019. The baseline patient characteristics, peri-operative factors, post-operative platelet counts and post-operative antithrombotic therapy were retrospectively collected from the electronic medical record. Results During the follow up period [median 662 days, interquartile range (IQR) 364 - 1116 days], 35 (21.6%) patients experienced a re-exploration for bleedings. The median time from a CF-LVAD implantation to re-exploration for bleedings was 6 days (IQR 1 - 10 days). In multivariate logistic regression analysis, a post-operative platelet count was the independent predictor for a re-exploration for bleedings after CF-LVAD implantation (per 104/μl: odds ratio 0.82, 95% confidence interval 0.74 - 0.91, p Conclusion A re-exploration for bleedings is prevalently needed after CF-LVAD implantation, especially in patients with low post-operative platelet counts. As bleedings requiring a re-exploration were associated with poor prognosis, the risk stratification using post-operative platelet counts may be beneficial for patients who underwent CF-LVAD implantation.

Purpose The development of cardiac allograft vasculopathy (CAV) is known to be induced by a biphasic process involving early intimal thickening and late constrictive remodeling. However, change of intimal thickening long-term period post heart transplantation (HTx) is still unknown. Our aim of this study was to investigate the change of intimal thickening of CAV long-term period post-HTx. Methods Intravascular ultrasound (IVUS) of coronary arteries were performed at 5 to 12 weeks after HTx (baseline) and repeated annually in all HTx recipients. And we reviewed the medical records of consecutive 102 HTx recipients who underwent serial intravascular ultrasounds from baseline to at least 1-year post HTx. ‘Progressive intimal thickening on IVUS’ was defined as an annual increase in maximal intimal thickness (MIT) of 0.3 mm or greater. The development of CAV included the any coronary revascularization, acute myocardial infarction and the coronary artery lesions classified ISHLT CAV 1 or 2. Results The progressive intimal thickening on IVUS was high incidence by 3 years post-HTx, however, was low after 3 years post-HTx (Figure 1). Also, similar trends were shown regardless of initiation of everolimus. The incidence of progressive intimal thickening on IVUS was higher in the early period than in the mid-term period (92.3% vs 25.0%, P Conclusion This long-term serial IVUS study supported that lumen loss on CAV occurred in a biphasic process consisting of the early intimal thickening and late constrictive remodeling. These results suggest that interventions to suppress an increase in intimal thickening is earlier needed within 3 years post-HTx, and also further treatment strategy to suppress the late constrictive remodeling on CAV are required.

Purpose Percutaneous driveline infection is a major complication after left ventricular assist device (LVAD) implantation, causing pump infection. Therefore, the precise diagnosis and evaluation of driveline infection are important. Recently, Fluor-18-fluorodeoxyglucose positron emission tomography is used for diagnosis of LVAD-specific and related infections. However, the role of Gallium-67 single-photon emission computed tomography (Ga-SPECT)-CT has not been fully elucidated. We investigated whether Ga-SPECT-CT predicts outcomes of patients with LVAD-specific percutaneous driveline infection. Methods Thirty-six patients with implantable continuous-flow LVAD, who underwent Ga-SPECT-CT to diagnose and evaluate percutaneous driveline infections, were enrolled and divided into uptake and no-uptake groups based on tracer concentration uptake on Ga-SPECT-CT. Main outcomes were surgical intervention (debridement, translocation of driveline exit site or pump exchange) and driveline-infection-caused readmission. Results Uptake on Ga-SPECT-CT revealed in 22 patients and regions of uptake were 9 (41%) driveline exit site, 10 (45%) subcutaneous driveline tunnel, and 3 (14%) sub-rectus driveline tunnel. No significant differences were noted in patient characteristics, wound appearance, and blood test. The prevalence of positive skin culture of driveline exit site as well as usage and duration of antibiotics did not differ (uptake vs no-uptake: 21/22, 95% vs 12/14, 86%, P = 0.30; 20/22, 91%, vs 11/14, 79%, P = 0.30; 20 vs 17 days, P = 0.19, respectively). However, the uptake group had a higher 1-year event rate (surgical intervention: 32% vs 0%, P = 0.037; readmission: 74% vs 6.9%, P = 0.0016). Conclusion Ga-SPECT-CT predicts surgical intervention and readmission in patients with LVAD-specific percutaneous driveline infection. Driveline infections with uptake on Ga-SPECT-CT require aggressive treatment including early surgical treatment.

Purpose Magnitude of functional recovery of the left ventricle (LV) is one of the critical determinants of prognosis post-implantation of ventricular assist device (iVAD) for non-ischemic dilated cardiomyopathy (NIDCM). Although predictive factors of the functional recovery are not fully understood, presence of immunocompetent cells in the myocardium is reported to be associated with the pathological stage and/or the myocardial viability. We aimed to explore relationships between functional recovery post-iVAD implantation and distribution of the immunocompetent cells in NIDCM. Methods In the last 5 years, iVAD such as HeartMateII was implanted in 50 patients with NIDCM for bridge-to-transplantation purpose, followed by β blocker and/or ACE inhibitor in the aim to enhance functional recovery. Results During the iVAD support, 12 patients (24%) underwent heart transplantation, while 2 patients (4%) died due to cerebral infarction. Four patients (8%) were treated for congestive heart failure in-hospital, while freedom from heart failure was 96±0.0% at 1 year and 89±0.1% at 5 years. Echocardiographical dimension of the LV was a significant predictive factor of heart failure post-iVAD implantation (P Conclusion Despite aggressive medical treatments post-iVAD implantation, functional recovery was not frequently seen in advanced stage of NIDCM. Immunocompetent cells in the LV myocardium might be a key to predict myocardial viability of this pathology.

Purpose Ventricular Assist devices are essential but challenging therapeutic options for advanced heart failure patients with critical conditions including cardiogenic shock. In such cases, bridge to decision (BTD) strategies using temporary mechanical circulatory (MCS) support should be introduced to stabilize the systemic conditions and to connect to the next therapeutic stages. We conducted a clinical study (NCVC-BTD_01, National Cerebral and Cardiovascular Center-Bridge to Decision_01) to assess the safety and effectiveness of the novel developed extracorporeal continuous-flow ventricular assist system employing a disposable and hydrodynamically leviated centrifugal pump (BR16010) for BTD strategies. Methods NCVC-BTD_01 is a single-center, single-arm, open-label, exploratory, medical device, investigator-initiated clinical study. The study was planned using Simon's minimax two-stage phase design. The primary endpoint is a composite of survival free of device-related serious adverse events and complications during device support. Results A total of nine patients (6 males, average 47.7±8.1 years) were enrolled for the study. Study subjects included 3 dilated cardiomyopathy, 3 fulminant myocarditis, 2 acute myocardial infarction and 1 chronic ischemic cardiomyopathy. Six patients were interagency registry for mechanically circulatory support (INTERMACS) profile 1 with temporary MCS and all remaining were INTERMACS profile 2. Eight patients received left ventricular support of which 3 initially received concomitant right ventricular support using extracorporeal membrane oxygenation circuit due to severe respiratory failure. One patient with fulminant myocarditis received biventricular support both using BR16010. After average of 19.0±13.5 days of support (Range, 9 to 48 days), 3 patients weaned from BR16010 because of native cardiac recovery, whereas 6 patients without cardiac recovery required conversion to durable implantable LVAD for bridge to transplantation. Although 1 patient developed non-disabling ischemic stroke, no patient died during the study period. Conclusion From the result of NCVC-BTD_01, BTD strategies using BR16010 safely and successfully bridged patients with advanced heart failure to the next therapeutic stages.

Purpose It is well known that aortic insufficiency (AI) is related to poor prognosis during left ventricular assisting device (LVAD) support. Since AHA announced destination therapy as a Class I therapy, weight is attached to AI management. We investigated the pathological change of the aortic valve after long-term LVAD support. Methods and Materials Thirty-three hearts removed at heart transplantation were investigated. Twenty-nine patients were supported by extracorporeal pulsatile device (Nipro-LVAD) and 4 patients by implantable devices (Heartmate II, Jarvik 2000, Novacor, EVAHEART, 1 case each). We compared the histological change of the aortic valve with the results of echocardiogram. Results The mean duration of LVAD support until heart transplantation was 972±324 (ranged from 416 to 1697) days. Although AI was detected in only one patient before LVAD implantation, it was detected in 19 patients before the transplantation. Pathological examination revealed that the aortic valve became thinner in all patients, ranged from 120 to 1400 micrometer. Micro thrombus on cusps and collagen proliferation in the spongiosa layer were also recognized. [ figure 1 ] Partial aortic valve fusion was seen in 4 recipients and curling of cusp tips was detected in 22 patients. Statistically, there was no close correlation between aortic valve thickness and LVAS support duration time, the grade of AI, nor cardiac function. Conclusions Degenerative aortic valve change was recognized after long-term LVAD support. Now that implantable continuous flow LVAD becomes the mainstream, we need to take more notice of AI during LVAD support.