- Email: [email protected]
Combined Transcatheter Aortic Valve Replacement and Thoracic Endovascular Aortic Repair Using Transapical Access
Ann Thorac Surg 2015;100:723–7
induction of general anesthesia, 250 mg of methylprednisolone, 100 mg of ranitidine, and 50 mg of diphenhydramine were given intravenously. Another 25 mg of intravenous diphenhydramine was given during the rewarming phase of cardiopulmonary bypass. During the procedure, the patient was on cardiopulmonary bypass for 3 hours and 52 minutes and a total time of 1 hour and 1 minute of deep hypothermic circulatory arrest (DHCA). During DHCA his blood temperature ranged from 21.6 to 17 C. Blood tryptase levels were sent after induction of anesthesia and after sternal closure; the results were 4.2 and 4.0 ng/mL, respectively. The case proceeded uneventfully without any signs of exacerbation of his coldinduced urticaria. He required low-dose norepinephrine and milrinone to separate from bypass. The norepinephrine was stopped prior to exiting the operating room, while the milrinone was continued into the intensive care unit. He was extubated the next morning and was discharged from the hospital on postoperative day 8. His recovery was uneventful, with no features of coldinduced urticaria.
Comment
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
723
References 1. Katsarou-Katsari A, Makris M, Lagogianni E, Gregoriou S, Theoharides T, Kalogeromitros D. Clinical features and natural history of acquired cold urticaria in a tertiary referral hospital: a 10-year prospective study. J Eur Acad Dermatol Venereol 2008;22:1405–11. 2. Shenoy V, Anton JM, Collard CD, Youngblood SC. Pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension. Anesthesiology 2014;120:1255–61. 3. Johnston WE, Moss J, Philbin DM, et al. Management of cold urticaria during hypothermia cardiopulmonary bypass. New Eng J Med 1982;306:219–21. 4. Booth K, Parissis H. Management of cold-induced urticaria during cardiac surgery. J Card Surg 2011;26:158–9. 5. Lancey RA, Schaefer OP, McCormick MJ. Coronary artery bypass grafting and aortic valve replacement with cold cardioplegia in a patient with cold induced urticaria. Ann Allergy Asthma Immunol 2004;92:273–5. 6. Bakay C, Onan B, Onan IS, Ozkara A. Coronary artery bypass grafting in cold-induced urticaria. Ann Thorac Surg 2010;89: 949–51.
Combined Transcatheter Aortic Valve Replacement and Thoracic Endovascular Aortic Repair Using Transapical Access Keith B. Allen, MD, Lesley M. Johnson, BA, A. Michael Borkon, MD, Sanjeev Aggarwal, MD, J. Russell Davis, MD, David J. Cohen, MD, Adnan K. Chhatriwalla, MD, Aaron Grantham, MD, and Anthony Hart, MD Departments of Cardiothoracic/Vascular Surgery and Cardiology, St. Luke’s Mid America Heart & Vascular Institute, Kansas City, Missouri
Vascular complications remain an important consideration when selecting access for delivery of large endovascular devices. With the advent of transcatheter aortic valve replacement, transapical access has become an acceptable technique when transfemoral or direct transaortic access is contraindicated. We report the use of the transapical approach during thoracic aortic endovascular repair in 2 patients, one of which included concomitant delivery of a transcatheter aortic valve replacement device. To our knowledge, this is the first reported case of a hybrid single-stage transcatheter aortic valve replacement and thoracic aortic endovascular repair using transapical access. (Ann Thorac Surg 2015;100:723–7) Ó 2015 by The Society of Thoracic Surgeons
Accepted for publication Oct 10, 2014. Address correspondence to Dr Allen, 4320 Wornall Rd, Medical Plaza II, Ste 50, Kansas City, MO 64111; e-mail: [email protected].
Dr Cohen discloses a financial relationship with Edwards Lifesciences.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.10.024
FEATURE ARTICLES
Acquired cold urticaria is an idiopathic condition associated with the development of urticaria after exposure to cold temperatures. The average age of onset is approximately 30 years of age, although it has been reported to occur from age of 3 months up to 74 years. Females and males are affected equally. Most patients (90%) will exhibit reactions with exposure to cold water, while a smaller number (29%) report symptoms upon contact with a cold surface. Nearly 33% will exhibit severe systemic reactions including hypotension and or respiratory distress [1]. Diagnosis is based primarily on cold induction testing as well as a detailed history of events leading to urticarial or allergic symptoms. A PTE is the gold standard for management of patients with chronic thrombotic pulmonary arterial hypertension. Deep hypothermic circulatory arrest is utilized to obtain a bloodless field due to the significant amount of collateral and bronchial blood flow in these patients [2]. Although no large-scale studies have been done to date investigating the safety of induced hypothermia in patients with cold-induced urticaria, we have shown with this case that DHCA to 17 C can be safely performed. With the potential for hypothermia to induce anaphylaxis in patients with cold-induced urticaria, great care must be taken to minimize histamine release during any hypothermic procedure. Previous case reports have utilized various management strategies in order to stabilize mast cells and minimize histamine release [3–6]. Although there is no current established standard perioperative pharmacologic regimen, antihistamines are the classic pharmacologic treatment for cold-induced urticaria [1]. The H1 and H2 blockers were utilized in this patient as well as steroids in order to decrease histamine release and its physiologic effects. The normal serum tryptase levels and lack of clinical signs and symptoms indicated the effectiveness of our therapy.
CASE REPORT ALLEN ET AL TAVR AND TEVAR BY TRANSAPICAL ACCESS
724
CASE REPORT ALLEN ET AL TAVR AND TEVAR BY TRANSAPICAL ACCESS
Ann Thorac Surg 2015;100:723–7
T
ransfemoral access has typically been used for device delivery during thoracic aortic endovascular repair (TEVAR); however, vascular access complications remain a concern and are reported in 2% to 17% of large devices delivered using transfemoral access [1, 2]. With the advent of transcatheter aortic valve replacement (TAVR), additional vascular access options, such as direct ascending aortic, subclavian, iliac, and transapical, have expanded the options for endovascular management of complicated patients requiring delivery of large endovascular devices. We report the use of the transapical approach during TEVAR in 2 patients, one of which included concomitant delivery of a TAVR device. To our knowledge, this is the first report of a hybrid single-stage TAVR and TEVAR using transapical access.
Case Reports
FEATURE ARTICLES
Patient 1 A 60-year-old woman presented urgently with a symptomatic 9-cm thoracic aortic aneurysm (Fig 1). Computed tomography demonstrated aneurysmal involvement of the left subclavian artery and inadequate iliofemoral access for a large-caliber sheath. In light of our experience with transapical TAVR, we planned TEVAR using transapical access with planned coverage of the left subclavian artery. The procedure was performed in a hybrid operating room. Transfemoral access was obtained, and a pigtail catheter was positioned in the ascending aorta. The initial angiogram demonstrated the large aneurysm with an adequate landing area in zone 2 (Fig 2). Exposure of the left ventricular apex was performed in a standard fashion as described for TAVR using a limited left anterolateral thoracotomy and a CardioVations (Edwards Lifesciences,
Fig 1. Computed tomography shows a symptomatic 9-cm thoracic aortic aneurysm.
Fig 2. The initial transfemoral angiogram demonstrates a large aneurysm with an adequate proximal landing area in zone 2, with planned left subclavian artery coverage.
Irvine, CA) soft tissue retractor with minimal rib distraction (Fig 3) [3]. Under fluoroscopic guidance, the left ventricular cavity was accessed with a needle, and the aortic valve was crossed with 0.035-inch wire. An angle guide catheter was used to direct the 0.035-inch wire into the descending thoracic aorta, and then the wire was exchanged for an Amplatz Super Stiff (Boston Scientific, Marlborough, MA) or Lunderquist (Cook Medical Inc, Bloomington, IN) wire. To minimize the time that the large delivery sheath was within the left ventricular (LV) cavity, an angiogram was performed to determine the distal landing zone before insertion of a 22F Dryseal (W.L. Gore and Associates, Flagstaff, AZ) sheath into the LV cavity (Fig 3). A 28-mm 15-cm Conformable GORE TAG (CTAG) graft (W.L. Gore and Associates) was then positioned and deployed distally. After angiography confirmed proper proximal graft positioning, a 31-mm 15-cm CTAG graft was deployed, landing in zone 2 and covering the left subclavian artery (Fig 3). A Tri-Lobe balloon (W.L. Gore and Associates) was used to postdilate the overlap between the graft components and to optimize the seal at the distal and proximal landing zone. A completion angiogram demonstrated no endoleak (Fig 4). The 22F delivery sheath was removed and the LV apex secured. The patient’s postoperative course was uncomplicated, and she was discharged home on postoperative day 4, without complications. Clinical and computed tomography (CT) follow-up at 1 year demonstrated no left arm symptoms, with collateralization of the covered left subclavian artery and no endoleak (Fig 4).
Ann Thorac Surg 2015;100:723–7
CASE REPORT ALLEN ET AL TAVR AND TEVAR BY TRANSAPICAL ACCESS
725
Fig 3. (A) The left ventricular apex was exposed using a limited left anterolateral thoracotomy and a soft tissue retractor with minimal rib distraction. (B) The left ventricular (LV) apex was accessed, and a stiff wire was placed across the aortic valve to insert the 22F delivery sheath. (C) The distal thoracic endograft was deployed, and the proximal endograft was positioned for a zone 2 landing, with coverage of the left subclavian artery.
Patient 2
coronaries. The Society of Thoracic Surgeons calculated risk for surgical mortality with conventional aortic valve replacement was 18%, which did not take into account her prior and current aortic pathology. A less invasive option was pursued, and she was felt to be a candidate for concomitant TAVR and TEVAR. A percutaneous approach was desired for this procedure. A review of her abdominal CTA, however, revealed that her prior SMA stent protruded significantly into the aorta, making safe passage and withdrawal of large endovascular devices during transfemoral TAVR/ TEVAR questionable (Fig 6). Given our familiarity with transapical TAVR and our recent successful experience using transapical access for TEVAR, we planned a concomitant single-stage TAVR/TEVAR using transapical access. The combined TAVR/TEVAR procedure was performed in the hybrid operating room. Percutaneous Fig 4. (A) An intraoperative completion angiogram shows good graft position in zone 2, a patent left common carotid artery, and coverage of the left subclavian artery, without endoleak. (B) Computed tomography at 1 year demonstrates a collateralized left subclavian artery and no endoleak.
FEATURE ARTICLES
An 89-year-old woman, while traveling away from her home state, presented at the emergency department with New York Heart Association class IV congestive heart failure (CHF), with associated severe back and left shoulder pain. Pertinent history was positive for known critical aortic stenosis (AS), for which she had been deemed “inoperable” because of a history of a complicated type B aortic dissection with malperfusion. This had resulted in left kidney infarct, with successful management of her intestinal ischemia with placement of a superior mesenteric artery (SMA) stent. Echocardiogram confirmed critical AS with a mean gradient of 66 mm Hg and a calculated aortic valve area of 0.5 cm2. A CT angiogram (CTA) demonstrated an 8-cm thoracic aortic aneurysm with surrounding hematoma (Fig 5). Cardiac catheterization demonstrated normal
726
CASE REPORT ALLEN ET AL TAVR AND TEVAR BY TRANSAPICAL ACCESS
Ann Thorac Surg 2015;100:723–7
FEATURE ARTICLES
Fig 5. (A) A computed tomography angiogram shows an 8-cm thoracic aortic aneurysm with surrounding hematoma. (B) Sagittal three-dimensional reconstruction demonstrates aortic deformity and the entry site of the previous type B dissection.
femoral arterial and venous access was obtained, and a pigtail catheter was positioned in the noncoronary cusp of the aortic valve and a temporary pacing catheter was placed in the right ventricle. An angiogram was obtained to determine the appropriate TAVR deployment angles. The LV apex was then exposed, stiff wire access was obtained across the aortic valve down into the abdominal aorta, and a 24F transapical TAVR delivery sheath (Edwards Lifesciences) was inserted into the LV cavity. We performed TEVAR first to avoid manipulation and crossing of a freshly deployed percutaneous valve. Angiography demonstrated an appropriate zone 3 landing area and a 36-mm 20-cm CTAG graft was deployed. A Tri-Lobe balloon was used to gently postdilate the endograft using rapid ventricular pacing to avoid inadvertent stent movement. A completion angiogram demonstrated good endograft position, without endoleak. TAVR was performed next. Fluoroscopy was repositioned to the previously obtained deployment angles, and Fig 6. Abdominal computed tomography shows (A) the previous superior mesenteric artery stent (arrow) protruding significantly into the aorta lumen, (B) making questionable safe passage and withdrawal of large endovascular devices during transfemoral transcatheter aortic valve replacement/ thoracic aortic endovascular repair (arrow).
a 26-mm Sapian (Edwards Lifesciences) percutaneous aortic valve was successfully implanted using rapid ventricular pacing. Transesophageal echocardiography demonstrated good valve positioning with trivial posterior perivalvular leak. The 24F delivery sheath was removed and the LV apex secured. The patient’s postoperative course was uncomplicated, with discharge to home on postoperative day 7. A CTA at the 6-month follow-up showed the endograft was in excellent position, without an endoleak (Fig 7). A transthoracic echocardiogram demonstrated a persistent trivial posterior perivalvular leak, with the patient living independently at home with her husband, without heart failure symptoms.
Comment Despite design improvements in endograft systems, including smaller delivery sheaths, inadequate arterial
Ann Thorac Surg 2015;100:723–7
CASE REPORT ALLEN ET AL TAVR AND TEVAR BY TRANSAPICAL ACCESS
727
References Fig 7. Computed tomography at the 6-month follow-up shows the skirt of the percutaneous valve and the endograft in excellent position, without an endoleak.
access and limited landing zones continue to present challenges in patients with complex aortic pathology. With the introduction of TAVR, the apex of the LV has gained popularity as the largest on ramp to the vascular highway. In 2009, Grenon and colleagues [4] first reported the use of transapical access for TEVAR in a pig model, with subsequent human case reports following [5–8]. Transapical access, aside from the ability to deliver a large device in a patient with inadequate iliofemoral vessels, may offer additional advantages in complex patients. The proximity of the LV apex provides a short working distance to the aortic pathology being treated with the potential for a more stable and better wire configuration across the aortic arch. In addition, the shorter working distance allows for better control of wire tension, and in conjunction with rapid ventricular pacing, permits precise deployment of the endograft. We have not found it necessary to use techniques describing “through-and-through” wire from the apex
1. Smith CR, Leon MB, Mack MK, et al. Transcatheter versus surgical aortic valve replacement in high risk patients. N Engl J Med 2011;364:2187–98. 2. Huang P, McCabe J, Kaneko T, et al. Incidence of vascular complications in transfemoral transcatheter aortic valve replacement according to femoral artery access technique. J Am Coll Cardiol 2014;63:A445. 3. Cheung A, Lichtenstein KM. Illustrated techniques for transapical aortic valve implantation. Ann Cardiothorac Surg 2012;1:231–9. 4. Grenon SM, MacDonald S, Sidhu RS, et al. Successful ventricular transapical thoracic endovascular graft deployment in a pig model. J Vasc Surg 2008;48:1301–5. 5. Ramponi F, Stephen MS, Wilson MK, Vallely MP. Think differently: trans-apical platform for TEVAR. Ann Cardiothorac Surg 2012;1:412–6. 6. MacDonald S, Cheung A, Sidhu R, et al. Endovascular aortic aneurysm repair via the left ventricular apex of a beating heart. J Vasc Surg 2009;49:759–62. 7. Szeto WY, Moser WG, Desai ND, et al. Transapical deployment of endovascular thoracic aortic stent graft for an ascending aortic pseudoaneurysm. Ann Thorac Surg 2010;89:616–8. 8. Uthoff H, Garcia-Covarrubias L, Samuels S, et al. Transapical endovascular aortic repair to treat complex aortic pathologies. Ann Thorac Surg 2012;93:1735–7. 9. Feezor RJ, Beaver TM. Antegrade deployment of a thoracic endograft using a minithoracotomy. Ann Thorac Surg 2014;98:713–5. 10. Komio CM, Vallabhajosyula P, Bavaria JE, et al. Combined transaortic transcatheter valve replacement and thoracic endografting. Ann Thorac Surg 2014;97:696–8.
FEATURE ARTICLES
of the LV to the femoral access as a means to stabilize the stiff wire [5]. Transapical access may be less desirable in patients with severe pulmonary or LV dysfunction. Recent case reports of direct transaortic deployment of a thoracic endograft using a right minithoracotomy [9] or combined TAVR/TEVAR through a partial sternotomy [10] provide additional access options for device delivery. Because thoracic endografts were designed to be delivered in a retrograde fashion, it is important appreciate any differences between the proximal and distal ends of each brand of graft. In the case of the CTAG graft used in both of these patients, the conventional proximal end has open, uncovered cells and more radial force compared with the conventional distal end with less radial force and completely covered cells. These differences need to be considered when deploying these grafts in an antegrade fashion, particularly if used off-label in patients with marginal landing zones. Although more invasive, transapical TEVAR is effective at treating complex aortic pathology and can be safely combined with TAVR in patients with inadequate retrograde access. Furthermore, the short working distance provided by transapical access may offer additional advantages regarding wire configuration and tension control when working within the curvature of the aortic arch. To our knowledge, this is the first report of a combined TAVR/TEVAR procedure using transapical access.
induction of general anesthesia, 250 mg of methylprednisolone, 100 mg of ranitidine, and 50 mg of diphenhydramine were given intravenously. Another 25 mg of intravenous diphenhydramine was given during the rewarming phase of cardiopulmonary bypass. During the procedure, the patient was on cardiopulmonary bypass for 3 hours and 52 minutes and a total time of 1 hour and 1 minute of deep hypothermic circulatory arrest (DHCA). During DHCA his blood temperature ranged from 21.6 to 17 C. Blood tryptase levels were sent after induction of anesthesia and after sternal closure; the results were 4.2 and 4.0 ng/mL, respectively. The case proceeded uneventfully without any signs of exacerbation of his coldinduced urticaria. He required low-dose norepinephrine and milrinone to separate from bypass. The norepinephrine was stopped prior to exiting the operating room, while the milrinone was continued into the intensive care unit. He was extubated the next morning and was discharged from the hospital on postoperative day 8. His recovery was uneventful, with no features of coldinduced urticaria.
Comment
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
723
References 1. Katsarou-Katsari A, Makris M, Lagogianni E, Gregoriou S, Theoharides T, Kalogeromitros D. Clinical features and natural history of acquired cold urticaria in a tertiary referral hospital: a 10-year prospective study. J Eur Acad Dermatol Venereol 2008;22:1405–11. 2. Shenoy V, Anton JM, Collard CD, Youngblood SC. Pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension. Anesthesiology 2014;120:1255–61. 3. Johnston WE, Moss J, Philbin DM, et al. Management of cold urticaria during hypothermia cardiopulmonary bypass. New Eng J Med 1982;306:219–21. 4. Booth K, Parissis H. Management of cold-induced urticaria during cardiac surgery. J Card Surg 2011;26:158–9. 5. Lancey RA, Schaefer OP, McCormick MJ. Coronary artery bypass grafting and aortic valve replacement with cold cardioplegia in a patient with cold induced urticaria. Ann Allergy Asthma Immunol 2004;92:273–5. 6. Bakay C, Onan B, Onan IS, Ozkara A. Coronary artery bypass grafting in cold-induced urticaria. Ann Thorac Surg 2010;89: 949–51.
Combined Transcatheter Aortic Valve Replacement and Thoracic Endovascular Aortic Repair Using Transapical Access Keith B. Allen, MD, Lesley M. Johnson, BA, A. Michael Borkon, MD, Sanjeev Aggarwal, MD, J. Russell Davis, MD, David J. Cohen, MD, Adnan K. Chhatriwalla, MD, Aaron Grantham, MD, and Anthony Hart, MD Departments of Cardiothoracic/Vascular Surgery and Cardiology, St. Luke’s Mid America Heart & Vascular Institute, Kansas City, Missouri
Vascular complications remain an important consideration when selecting access for delivery of large endovascular devices. With the advent of transcatheter aortic valve replacement, transapical access has become an acceptable technique when transfemoral or direct transaortic access is contraindicated. We report the use of the transapical approach during thoracic aortic endovascular repair in 2 patients, one of which included concomitant delivery of a transcatheter aortic valve replacement device. To our knowledge, this is the first reported case of a hybrid single-stage transcatheter aortic valve replacement and thoracic aortic endovascular repair using transapical access. (Ann Thorac Surg 2015;100:723–7) Ó 2015 by The Society of Thoracic Surgeons
Accepted for publication Oct 10, 2014. Address correspondence to Dr Allen, 4320 Wornall Rd, Medical Plaza II, Ste 50, Kansas City, MO 64111; e-mail: [email protected].
Dr Cohen discloses a financial relationship with Edwards Lifesciences.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.10.024
FEATURE ARTICLES
Acquired cold urticaria is an idiopathic condition associated with the development of urticaria after exposure to cold temperatures. The average age of onset is approximately 30 years of age, although it has been reported to occur from age of 3 months up to 74 years. Females and males are affected equally. Most patients (90%) will exhibit reactions with exposure to cold water, while a smaller number (29%) report symptoms upon contact with a cold surface. Nearly 33% will exhibit severe systemic reactions including hypotension and or respiratory distress [1]. Diagnosis is based primarily on cold induction testing as well as a detailed history of events leading to urticarial or allergic symptoms. A PTE is the gold standard for management of patients with chronic thrombotic pulmonary arterial hypertension. Deep hypothermic circulatory arrest is utilized to obtain a bloodless field due to the significant amount of collateral and bronchial blood flow in these patients [2]. Although no large-scale studies have been done to date investigating the safety of induced hypothermia in patients with cold-induced urticaria, we have shown with this case that DHCA to 17 C can be safely performed. With the potential for hypothermia to induce anaphylaxis in patients with cold-induced urticaria, great care must be taken to minimize histamine release during any hypothermic procedure. Previous case reports have utilized various management strategies in order to stabilize mast cells and minimize histamine release [3–6]. Although there is no current established standard perioperative pharmacologic regimen, antihistamines are the classic pharmacologic treatment for cold-induced urticaria [1]. The H1 and H2 blockers were utilized in this patient as well as steroids in order to decrease histamine release and its physiologic effects. The normal serum tryptase levels and lack of clinical signs and symptoms indicated the effectiveness of our therapy.
CASE REPORT ALLEN ET AL TAVR AND TEVAR BY TRANSAPICAL ACCESS
724
CASE REPORT ALLEN ET AL TAVR AND TEVAR BY TRANSAPICAL ACCESS
Ann Thorac Surg 2015;100:723–7
T
ransfemoral access has typically been used for device delivery during thoracic aortic endovascular repair (TEVAR); however, vascular access complications remain a concern and are reported in 2% to 17% of large devices delivered using transfemoral access [1, 2]. With the advent of transcatheter aortic valve replacement (TAVR), additional vascular access options, such as direct ascending aortic, subclavian, iliac, and transapical, have expanded the options for endovascular management of complicated patients requiring delivery of large endovascular devices. We report the use of the transapical approach during TEVAR in 2 patients, one of which included concomitant delivery of a TAVR device. To our knowledge, this is the first report of a hybrid single-stage TAVR and TEVAR using transapical access.
Case Reports
FEATURE ARTICLES
Patient 1 A 60-year-old woman presented urgently with a symptomatic 9-cm thoracic aortic aneurysm (Fig 1). Computed tomography demonstrated aneurysmal involvement of the left subclavian artery and inadequate iliofemoral access for a large-caliber sheath. In light of our experience with transapical TAVR, we planned TEVAR using transapical access with planned coverage of the left subclavian artery. The procedure was performed in a hybrid operating room. Transfemoral access was obtained, and a pigtail catheter was positioned in the ascending aorta. The initial angiogram demonstrated the large aneurysm with an adequate landing area in zone 2 (Fig 2). Exposure of the left ventricular apex was performed in a standard fashion as described for TAVR using a limited left anterolateral thoracotomy and a CardioVations (Edwards Lifesciences,
Fig 1. Computed tomography shows a symptomatic 9-cm thoracic aortic aneurysm.
Fig 2. The initial transfemoral angiogram demonstrates a large aneurysm with an adequate proximal landing area in zone 2, with planned left subclavian artery coverage.
Irvine, CA) soft tissue retractor with minimal rib distraction (Fig 3) [3]. Under fluoroscopic guidance, the left ventricular cavity was accessed with a needle, and the aortic valve was crossed with 0.035-inch wire. An angle guide catheter was used to direct the 0.035-inch wire into the descending thoracic aorta, and then the wire was exchanged for an Amplatz Super Stiff (Boston Scientific, Marlborough, MA) or Lunderquist (Cook Medical Inc, Bloomington, IN) wire. To minimize the time that the large delivery sheath was within the left ventricular (LV) cavity, an angiogram was performed to determine the distal landing zone before insertion of a 22F Dryseal (W.L. Gore and Associates, Flagstaff, AZ) sheath into the LV cavity (Fig 3). A 28-mm 15-cm Conformable GORE TAG (CTAG) graft (W.L. Gore and Associates) was then positioned and deployed distally. After angiography confirmed proper proximal graft positioning, a 31-mm 15-cm CTAG graft was deployed, landing in zone 2 and covering the left subclavian artery (Fig 3). A Tri-Lobe balloon (W.L. Gore and Associates) was used to postdilate the overlap between the graft components and to optimize the seal at the distal and proximal landing zone. A completion angiogram demonstrated no endoleak (Fig 4). The 22F delivery sheath was removed and the LV apex secured. The patient’s postoperative course was uncomplicated, and she was discharged home on postoperative day 4, without complications. Clinical and computed tomography (CT) follow-up at 1 year demonstrated no left arm symptoms, with collateralization of the covered left subclavian artery and no endoleak (Fig 4).
Ann Thorac Surg 2015;100:723–7
CASE REPORT ALLEN ET AL TAVR AND TEVAR BY TRANSAPICAL ACCESS
725
Fig 3. (A) The left ventricular apex was exposed using a limited left anterolateral thoracotomy and a soft tissue retractor with minimal rib distraction. (B) The left ventricular (LV) apex was accessed, and a stiff wire was placed across the aortic valve to insert the 22F delivery sheath. (C) The distal thoracic endograft was deployed, and the proximal endograft was positioned for a zone 2 landing, with coverage of the left subclavian artery.
Patient 2
coronaries. The Society of Thoracic Surgeons calculated risk for surgical mortality with conventional aortic valve replacement was 18%, which did not take into account her prior and current aortic pathology. A less invasive option was pursued, and she was felt to be a candidate for concomitant TAVR and TEVAR. A percutaneous approach was desired for this procedure. A review of her abdominal CTA, however, revealed that her prior SMA stent protruded significantly into the aorta, making safe passage and withdrawal of large endovascular devices during transfemoral TAVR/ TEVAR questionable (Fig 6). Given our familiarity with transapical TAVR and our recent successful experience using transapical access for TEVAR, we planned a concomitant single-stage TAVR/TEVAR using transapical access. The combined TAVR/TEVAR procedure was performed in the hybrid operating room. Percutaneous Fig 4. (A) An intraoperative completion angiogram shows good graft position in zone 2, a patent left common carotid artery, and coverage of the left subclavian artery, without endoleak. (B) Computed tomography at 1 year demonstrates a collateralized left subclavian artery and no endoleak.
FEATURE ARTICLES
An 89-year-old woman, while traveling away from her home state, presented at the emergency department with New York Heart Association class IV congestive heart failure (CHF), with associated severe back and left shoulder pain. Pertinent history was positive for known critical aortic stenosis (AS), for which she had been deemed “inoperable” because of a history of a complicated type B aortic dissection with malperfusion. This had resulted in left kidney infarct, with successful management of her intestinal ischemia with placement of a superior mesenteric artery (SMA) stent. Echocardiogram confirmed critical AS with a mean gradient of 66 mm Hg and a calculated aortic valve area of 0.5 cm2. A CT angiogram (CTA) demonstrated an 8-cm thoracic aortic aneurysm with surrounding hematoma (Fig 5). Cardiac catheterization demonstrated normal
726
CASE REPORT ALLEN ET AL TAVR AND TEVAR BY TRANSAPICAL ACCESS
Ann Thorac Surg 2015;100:723–7
FEATURE ARTICLES
Fig 5. (A) A computed tomography angiogram shows an 8-cm thoracic aortic aneurysm with surrounding hematoma. (B) Sagittal three-dimensional reconstruction demonstrates aortic deformity and the entry site of the previous type B dissection.
femoral arterial and venous access was obtained, and a pigtail catheter was positioned in the noncoronary cusp of the aortic valve and a temporary pacing catheter was placed in the right ventricle. An angiogram was obtained to determine the appropriate TAVR deployment angles. The LV apex was then exposed, stiff wire access was obtained across the aortic valve down into the abdominal aorta, and a 24F transapical TAVR delivery sheath (Edwards Lifesciences) was inserted into the LV cavity. We performed TEVAR first to avoid manipulation and crossing of a freshly deployed percutaneous valve. Angiography demonstrated an appropriate zone 3 landing area and a 36-mm 20-cm CTAG graft was deployed. A Tri-Lobe balloon was used to gently postdilate the endograft using rapid ventricular pacing to avoid inadvertent stent movement. A completion angiogram demonstrated good endograft position, without endoleak. TAVR was performed next. Fluoroscopy was repositioned to the previously obtained deployment angles, and Fig 6. Abdominal computed tomography shows (A) the previous superior mesenteric artery stent (arrow) protruding significantly into the aorta lumen, (B) making questionable safe passage and withdrawal of large endovascular devices during transfemoral transcatheter aortic valve replacement/ thoracic aortic endovascular repair (arrow).
a 26-mm Sapian (Edwards Lifesciences) percutaneous aortic valve was successfully implanted using rapid ventricular pacing. Transesophageal echocardiography demonstrated good valve positioning with trivial posterior perivalvular leak. The 24F delivery sheath was removed and the LV apex secured. The patient’s postoperative course was uncomplicated, with discharge to home on postoperative day 7. A CTA at the 6-month follow-up showed the endograft was in excellent position, without an endoleak (Fig 7). A transthoracic echocardiogram demonstrated a persistent trivial posterior perivalvular leak, with the patient living independently at home with her husband, without heart failure symptoms.
Comment Despite design improvements in endograft systems, including smaller delivery sheaths, inadequate arterial
Ann Thorac Surg 2015;100:723–7
CASE REPORT ALLEN ET AL TAVR AND TEVAR BY TRANSAPICAL ACCESS
727
References Fig 7. Computed tomography at the 6-month follow-up shows the skirt of the percutaneous valve and the endograft in excellent position, without an endoleak.
access and limited landing zones continue to present challenges in patients with complex aortic pathology. With the introduction of TAVR, the apex of the LV has gained popularity as the largest on ramp to the vascular highway. In 2009, Grenon and colleagues [4] first reported the use of transapical access for TEVAR in a pig model, with subsequent human case reports following [5–8]. Transapical access, aside from the ability to deliver a large device in a patient with inadequate iliofemoral vessels, may offer additional advantages in complex patients. The proximity of the LV apex provides a short working distance to the aortic pathology being treated with the potential for a more stable and better wire configuration across the aortic arch. In addition, the shorter working distance allows for better control of wire tension, and in conjunction with rapid ventricular pacing, permits precise deployment of the endograft. We have not found it necessary to use techniques describing “through-and-through” wire from the apex
1. Smith CR, Leon MB, Mack MK, et al. Transcatheter versus surgical aortic valve replacement in high risk patients. N Engl J Med 2011;364:2187–98. 2. Huang P, McCabe J, Kaneko T, et al. Incidence of vascular complications in transfemoral transcatheter aortic valve replacement according to femoral artery access technique. J Am Coll Cardiol 2014;63:A445. 3. Cheung A, Lichtenstein KM. Illustrated techniques for transapical aortic valve implantation. Ann Cardiothorac Surg 2012;1:231–9. 4. Grenon SM, MacDonald S, Sidhu RS, et al. Successful ventricular transapical thoracic endovascular graft deployment in a pig model. J Vasc Surg 2008;48:1301–5. 5. Ramponi F, Stephen MS, Wilson MK, Vallely MP. Think differently: trans-apical platform for TEVAR. Ann Cardiothorac Surg 2012;1:412–6. 6. MacDonald S, Cheung A, Sidhu R, et al. Endovascular aortic aneurysm repair via the left ventricular apex of a beating heart. J Vasc Surg 2009;49:759–62. 7. Szeto WY, Moser WG, Desai ND, et al. Transapical deployment of endovascular thoracic aortic stent graft for an ascending aortic pseudoaneurysm. Ann Thorac Surg 2010;89:616–8. 8. Uthoff H, Garcia-Covarrubias L, Samuels S, et al. Transapical endovascular aortic repair to treat complex aortic pathologies. Ann Thorac Surg 2012;93:1735–7. 9. Feezor RJ, Beaver TM. Antegrade deployment of a thoracic endograft using a minithoracotomy. Ann Thorac Surg 2014;98:713–5. 10. Komio CM, Vallabhajosyula P, Bavaria JE, et al. Combined transaortic transcatheter valve replacement and thoracic endografting. Ann Thorac Surg 2014;97:696–8.
FEATURE ARTICLES
of the LV to the femoral access as a means to stabilize the stiff wire [5]. Transapical access may be less desirable in patients with severe pulmonary or LV dysfunction. Recent case reports of direct transaortic deployment of a thoracic endograft using a right minithoracotomy [9] or combined TAVR/TEVAR through a partial sternotomy [10] provide additional access options for device delivery. Because thoracic endografts were designed to be delivered in a retrograde fashion, it is important appreciate any differences between the proximal and distal ends of each brand of graft. In the case of the CTAG graft used in both of these patients, the conventional proximal end has open, uncovered cells and more radial force compared with the conventional distal end with less radial force and completely covered cells. These differences need to be considered when deploying these grafts in an antegrade fashion, particularly if used off-label in patients with marginal landing zones. Although more invasive, transapical TEVAR is effective at treating complex aortic pathology and can be safely combined with TAVR in patients with inadequate retrograde access. Furthermore, the short working distance provided by transapical access may offer additional advantages regarding wire configuration and tension control when working within the curvature of the aortic arch. To our knowledge, this is the first report of a combined TAVR/TEVAR procedure using transapical access.