LAUSR

This article refers to ‘Incidence and clinical correlates of de-novo aortic regurgitation with a fully magnetically levitated left ventricular assist device: a MOMENTUM 3 trial portfolio analysis’ by N. Uriel et al. , published in this issue on pages 286–294. Effective left ventricular assist device (LVAD) therapy is predicated on a competent aortic valve. The LVAD–aorta pathway paral-lels the native left ventricular (LV)–aorta circulatory pathway; but in the absence of native LV ejection, this parallel arrangement becomes a single serial arrangement of LV–LVAD–aorta. In both cases, aortic regurgitation (AR) ‘short circuits’ these pathways and compromises the efficacy of LVAD support. This is the basis for close scrutiny of the aortic valve prior to LVAD implantation. 1 However, even in patients without pre-existing AR, moderate/severe de novo AR has been reported in over 30% of patients after 3 years of LVAD support. 2 In this issue of the Journal, in an analysis of the MOMENTUM 3 trial, freedom from significant (moderate/severe) AR was 92 ± 2% at 2years in the centrifugal-flow HeartMate 3 LVAD group compared to 82 ± 2% in the axial-flow HeartMate II LVAD group ( p = 0.002). 3 This finding, with the usual caveats associated with analysis of a clinical trial dataset, including the limitations acknowledged by the authors, raises the intriguing possibility that the difference in LVAD physiology may contribute to the development or progression of de novo AR. Like most influential studies