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Percutaneous Aortic Valve Replacement Using a Subclavian Artery Graft
Percutaneous Aortic Valve Replacement Using a Subclavian Artery Graft Janny E. Poelman, CCRN, Rik W. van der Werf, MD, Yvonne L. Douglas, MD, PhD, Ad F.M. van den Heuvel, MD, PhD, Bart J.G.L. de Smet, MD, PhD, and Massimo A. Mariani, MD, PhD Departments of Cardiology and Thoracic Surgery, University Medical Center Groningen, Groningen, The Netherlands
Over the past few years transcatheter heart valve implantation (THI) has become an alternative treatment for aortic valve replacement. The THI does not require a midline sternotomy or cardiopulmonary bypass and can be performed through a transfemoral or a transapical approach. In case of severe peripheral vascular disease the transapical route is usually chosen. However, when the use of a small anterolateral thoracotomy is not preferred due to comorbidities, the subclavian artery can be considered as a third alternative route. This case report describes an approach for THI through the subclavian artery, by using a Dacron graft. (Ann Thorac Surg 2012;94:e95– 6) © 2012 by The Society of Thoracic Surgeons
S
ince the early 1960s, aortic valve replacement (AVR) has been routinely performed. Currently, AVR requires a midline sternotomy and cardiopulmonary bypass with cardioplegic arrest of the heart. Unfortunately, a high percentage of patients are, at present, not referred for surgical treatment, due mainly to their expected risk of complications or death [1]. Over the last few years the transcatheter heart valve implantation (THI) has been developed, and which does not require either midline sternotomy or cardiopulmonary bypass. The THI can be performed either through a transfemoral or a transapical approach. In the latter case a small anterolateral thoracotomy is required to introduce the valve through the apex of the left ventricle. Currently, 2 clinical devices are available for THI: the Edwards Sapien bovine bioprosthesis (Edwards Lifesciences, Irvine, CA) and the Medtronic CoreValve porcine self-expanding bioprosthesis (Medtronic Inc, Minneapolis, MN). Both available devices require careful sizing of the peripheral vasculature [2, 3]. In case of diffusely diseased femoral arteries or a borderline small size, the transapical route is usually preferred. However, when bad lung function or other comorbidities contraindicate the use of a small anterolateral thoracotomy, the subclavian artery can be considered as a third alternative route. This case report describes an approach for THI through the subclavian artery by using a Dacron graft (Terumo Vascular System Corp, Ann Arbor, MI) combined with a third-generation (18F) device for the positioning of a CoreValve aortic valve prosthesis.
Accepted for publication March 5, 2012. Address correspondence to Dr Mariani, Department of Thoracic Surgery, University Medical Center Groningen, PO box 30001, 9700 RB Groningen, The Netherlands; e-mail: [email protected].
© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
An 86-year-old female patient with severe symptomatic aortic stenosis was admitted to our hospital for preoperative evaluation for AVR. In 1981 she had undergone a mitral valve replacement (Björk Shiley) with redo surgery in 1991 because of a fractured disc. The patient’s medical history showed atrial fibrillation since 2001, pulmonary embolism with severely compromised long function, leg thrombosis, recent cerebral vascular accident with visual disorders, breast cancer, and renal insufficiency (estimated glomerular filtration rate 29 mL/minute). The left ventricular ejection fraction was 0.50 and the aortic valve area was 0.46 cm2, with a peak gradient between 83 and 128 mm Hg. Dyspnea was classified as class III heart failure according to the New York Heart Association. Due to a high expected operative risk (logistic European system for cardiac operative risk evaluation 44.8%; Society of Thoracic Surgeons risk score 56.4%) conventional AVR was dismissed. The patient was offered the option to further investigate the possibility of THI to which she consented. The aortic annulus was measured by transthoracic echocardiography at 22 mm. Angiographic assessment revealed favorable anatomy of the proximal ascending aorta and arch, but also calcified and diffusely diseased femoral arteries on both sides. Because neither transfemoral (due to peripheral vascular disease) nor transapical (due to compromised lung function) approaches were possible, the left subclavian artery was ultimately chosen as a route for THI. The procedure was performed under general anesthesia. The left subclavian artery was exposed through an 8-cm incision in the Mohrenheim fossa. The left side was preferred because of a favorable angle to the ascending aorta. After preparation of the pectoralis major and an incision in the clavipectoral fascia, the pectoralis minor was divided. The subclavian artery was brought into view using blunt technique. Care was taken not to injure the brachial plexus. Proximal and distal control of the subclavian artery was obtained. After administration of 5,000 international units heparin, an 8-mm Dacron graft was anastomosed end-toside to the subclavian artery with a running 6 – 0 polypropylene suture, leaving the full length of the Dacron graft available for the introducer system. The introducer system was inserted in the Dacron graft and snared with a thick silk suture to prevent blood loss (Fig 1A). The procedure was performed under transesophageal echocardiographic guidance. Balloon valvuloplasty was performed with a 20-mm balloon under rapid pacing before device placement. Subsequently, the device was deployed in a retrograde approach and placed in the annulus of the aortic valve under fluoroscopic guidance. Hemodynamic and echocardiographic outcome were assessed continuously during the procedure. Evaluation of postprocedural aortic valve regurgitation was performed using a supravalvular angiogram and transesophageal echocardiography (Fig 1B). At the end of the procedure, the Dacron graft was clipped close to the subclavian artery, cut off just distally of the clip, and oversewn. After the procedure, the patient was transferred to the coronary care unit. Within 2 days the patient was mobilized. Echocardiography showed a good function of the aortic valve without 0003-4975/$36.00 doi:10.1016/j.athoracsur.2012.03.017
e96
CASE REPORT POELMAN ET AL THI FOR AVR THROUGH THE SUBCLAVIAN ARTERY
Ann Thorac Surg 2012;94:e95– 6
Fig. 1. (A) Using the Dacron graft. (B) During deployment and after controlled release of the valve. (B, left) CoreValve placed in position. Insufflations of the balloon. (B, right) CoreValve fully expanded and correctly positioned.
leakage. At 1-year follow-up the patient was classified as class I-II heart failure, and echocardiography showed a good function of the aortic valve. The patient did not report any complaints regarding the left arm and shoulder.
Comment This case report shows the feasibility of the subclavian approach for THI. This technique can be used as an alternative technique, when neither transfemoral nor transapical approach are preferable. Although the subclavian approach for THI is not a novel technique [4, 5], the use of an end-to-side Dacron graft on the subclavian artery has not been reported before to the authors’ knowledge. The novelty of this approach is the use of the full length of the Dacron graft, enabling the insertion of the entire introducer device. With this technique the manipulation of the introducer system and delivery catheter are easier than with a direct approach to the subclavian artery. Furthermore, this technique may possibly reduce potential vascular injury to the subclavian artery and decrease the risk of postprocedural subclavian stenosis.
We thank H. Frenk and V. Cernak, Department of Anesthesiology, University Medical Center Groningen, for making pictures of the procedure and for providing them to us. We also thank Ms Sylvia Germes and Mr Robbert Vermeulen for the critical reading of the manuscript.
References 1. Van Geldorp MW, van Gameren M, Kappetein AP, et al. Therapeutic decisions for patients with symptomatic severe aortic stenosis: room for improvement? Eur J Cardiothorac Surg 2009;35:953–7. 2. Rodés-Cabau J. Progress in transcatheter aortic valve implantation. [Article in Spanish] Rev Esp Cardiol 2010;63:439 –50. 3. Rodés-Cabau J, Dumont E, De LaRochellière R, et al. Feasibility and initial results of percutaneous aortic valve implantation including selection of the transfemoral or transapical approach in patients with severe aortic stenosis. Am J Cardiol 2008;102:1240–6. 4. Petronio AS, De Carlo M, Bedogni F, et al. Safety and efficacy of the subclavian approach for the transcatheter aortic valve implantation with the CoreValve revalving system. Circ Cardiovasc Interv 2010;3:359 – 66. 5. Fraccaro C, Napodano M, Tarantini G, et al. Expanding the eligibility for transcatheter aortic valve implantation the transsubclavian retrograde approach using the III generation CoreValve revalving system. JACC Cardiovasc Interv 2009;2:828–33.
Over the past few years transcatheter heart valve implantation (THI) has become an alternative treatment for aortic valve replacement. The THI does not require a midline sternotomy or cardiopulmonary bypass and can be performed through a transfemoral or a transapical approach. In case of severe peripheral vascular disease the transapical route is usually chosen. However, when the use of a small anterolateral thoracotomy is not preferred due to comorbidities, the subclavian artery can be considered as a third alternative route. This case report describes an approach for THI through the subclavian artery, by using a Dacron graft. (Ann Thorac Surg 2012;94:e95– 6) © 2012 by The Society of Thoracic Surgeons
S
ince the early 1960s, aortic valve replacement (AVR) has been routinely performed. Currently, AVR requires a midline sternotomy and cardiopulmonary bypass with cardioplegic arrest of the heart. Unfortunately, a high percentage of patients are, at present, not referred for surgical treatment, due mainly to their expected risk of complications or death [1]. Over the last few years the transcatheter heart valve implantation (THI) has been developed, and which does not require either midline sternotomy or cardiopulmonary bypass. The THI can be performed either through a transfemoral or a transapical approach. In the latter case a small anterolateral thoracotomy is required to introduce the valve through the apex of the left ventricle. Currently, 2 clinical devices are available for THI: the Edwards Sapien bovine bioprosthesis (Edwards Lifesciences, Irvine, CA) and the Medtronic CoreValve porcine self-expanding bioprosthesis (Medtronic Inc, Minneapolis, MN). Both available devices require careful sizing of the peripheral vasculature [2, 3]. In case of diffusely diseased femoral arteries or a borderline small size, the transapical route is usually preferred. However, when bad lung function or other comorbidities contraindicate the use of a small anterolateral thoracotomy, the subclavian artery can be considered as a third alternative route. This case report describes an approach for THI through the subclavian artery by using a Dacron graft (Terumo Vascular System Corp, Ann Arbor, MI) combined with a third-generation (18F) device for the positioning of a CoreValve aortic valve prosthesis.
Accepted for publication March 5, 2012. Address correspondence to Dr Mariani, Department of Thoracic Surgery, University Medical Center Groningen, PO box 30001, 9700 RB Groningen, The Netherlands; e-mail: [email protected].
© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
An 86-year-old female patient with severe symptomatic aortic stenosis was admitted to our hospital for preoperative evaluation for AVR. In 1981 she had undergone a mitral valve replacement (Björk Shiley) with redo surgery in 1991 because of a fractured disc. The patient’s medical history showed atrial fibrillation since 2001, pulmonary embolism with severely compromised long function, leg thrombosis, recent cerebral vascular accident with visual disorders, breast cancer, and renal insufficiency (estimated glomerular filtration rate 29 mL/minute). The left ventricular ejection fraction was 0.50 and the aortic valve area was 0.46 cm2, with a peak gradient between 83 and 128 mm Hg. Dyspnea was classified as class III heart failure according to the New York Heart Association. Due to a high expected operative risk (logistic European system for cardiac operative risk evaluation 44.8%; Society of Thoracic Surgeons risk score 56.4%) conventional AVR was dismissed. The patient was offered the option to further investigate the possibility of THI to which she consented. The aortic annulus was measured by transthoracic echocardiography at 22 mm. Angiographic assessment revealed favorable anatomy of the proximal ascending aorta and arch, but also calcified and diffusely diseased femoral arteries on both sides. Because neither transfemoral (due to peripheral vascular disease) nor transapical (due to compromised lung function) approaches were possible, the left subclavian artery was ultimately chosen as a route for THI. The procedure was performed under general anesthesia. The left subclavian artery was exposed through an 8-cm incision in the Mohrenheim fossa. The left side was preferred because of a favorable angle to the ascending aorta. After preparation of the pectoralis major and an incision in the clavipectoral fascia, the pectoralis minor was divided. The subclavian artery was brought into view using blunt technique. Care was taken not to injure the brachial plexus. Proximal and distal control of the subclavian artery was obtained. After administration of 5,000 international units heparin, an 8-mm Dacron graft was anastomosed end-toside to the subclavian artery with a running 6 – 0 polypropylene suture, leaving the full length of the Dacron graft available for the introducer system. The introducer system was inserted in the Dacron graft and snared with a thick silk suture to prevent blood loss (Fig 1A). The procedure was performed under transesophageal echocardiographic guidance. Balloon valvuloplasty was performed with a 20-mm balloon under rapid pacing before device placement. Subsequently, the device was deployed in a retrograde approach and placed in the annulus of the aortic valve under fluoroscopic guidance. Hemodynamic and echocardiographic outcome were assessed continuously during the procedure. Evaluation of postprocedural aortic valve regurgitation was performed using a supravalvular angiogram and transesophageal echocardiography (Fig 1B). At the end of the procedure, the Dacron graft was clipped close to the subclavian artery, cut off just distally of the clip, and oversewn. After the procedure, the patient was transferred to the coronary care unit. Within 2 days the patient was mobilized. Echocardiography showed a good function of the aortic valve without 0003-4975/$36.00 doi:10.1016/j.athoracsur.2012.03.017
e96
CASE REPORT POELMAN ET AL THI FOR AVR THROUGH THE SUBCLAVIAN ARTERY
Ann Thorac Surg 2012;94:e95– 6
Fig. 1. (A) Using the Dacron graft. (B) During deployment and after controlled release of the valve. (B, left) CoreValve placed in position. Insufflations of the balloon. (B, right) CoreValve fully expanded and correctly positioned.
leakage. At 1-year follow-up the patient was classified as class I-II heart failure, and echocardiography showed a good function of the aortic valve. The patient did not report any complaints regarding the left arm and shoulder.
Comment This case report shows the feasibility of the subclavian approach for THI. This technique can be used as an alternative technique, when neither transfemoral nor transapical approach are preferable. Although the subclavian approach for THI is not a novel technique [4, 5], the use of an end-to-side Dacron graft on the subclavian artery has not been reported before to the authors’ knowledge. The novelty of this approach is the use of the full length of the Dacron graft, enabling the insertion of the entire introducer device. With this technique the manipulation of the introducer system and delivery catheter are easier than with a direct approach to the subclavian artery. Furthermore, this technique may possibly reduce potential vascular injury to the subclavian artery and decrease the risk of postprocedural subclavian stenosis.
We thank H. Frenk and V. Cernak, Department of Anesthesiology, University Medical Center Groningen, for making pictures of the procedure and for providing them to us. We also thank Ms Sylvia Germes and Mr Robbert Vermeulen for the critical reading of the manuscript.
References 1. Van Geldorp MW, van Gameren M, Kappetein AP, et al. Therapeutic decisions for patients with symptomatic severe aortic stenosis: room for improvement? Eur J Cardiothorac Surg 2009;35:953–7. 2. Rodés-Cabau J. Progress in transcatheter aortic valve implantation. [Article in Spanish] Rev Esp Cardiol 2010;63:439 –50. 3. Rodés-Cabau J, Dumont E, De LaRochellière R, et al. Feasibility and initial results of percutaneous aortic valve implantation including selection of the transfemoral or transapical approach in patients with severe aortic stenosis. Am J Cardiol 2008;102:1240–6. 4. Petronio AS, De Carlo M, Bedogni F, et al. Safety and efficacy of the subclavian approach for the transcatheter aortic valve implantation with the CoreValve revalving system. Circ Cardiovasc Interv 2010;3:359 – 66. 5. Fraccaro C, Napodano M, Tarantini G, et al. Expanding the eligibility for transcatheter aortic valve implantation the transsubclavian retrograde approach using the III generation CoreValve revalving system. JACC Cardiovasc Interv 2009;2:828–33.