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Prosthetic aortic valve removal from the abdominal aorta after successful “valve-through” TAVI
International Journal of Cardiology 164 (2013) e27–e28
Contents lists available at SciVerse ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Prosthetic aortic valve removal from the abdominal aorta after successful “valve-through” TAVI George Latsios a, Konstantinos Toutouzas a, Dimitris Tousoulis a,⁎, Konstantinos Stathogiannis a, Costas Tentolouris a, Andreas Synetos a, Konstantinos Filis b, Christodoulos Stefanadis a a b
First Cardiology Department of Athens Medical School, Hippokration Hospital, Athens, Greece Department of Vascular Surgery, Athens Medical School, Athens, Greece
a r t i c l e
i n f o
Article history: Received 13 September 2012 Accepted 25 September 2012 Available online 12 October 2012 Keywords: Aortic stenosis Aortic valve TAVI Core valve
Trans-catheter aortic valve implantation (TAVI) is the treatment of choice for high-risk inoperable patients with severe symptomatic aortic valve stenosis (AVS). An 85-year-old male patient with severe symptomatic AVS was referred for TAVI; with a logistic EuroSCORE of 20.21%. During its deployment, the 29 mm CoreValve (CV) prosthesis was ejected out of its intended anatomic position, in a supra-annular level. Because that happened at two-thirds of the deployment, we decided to retract the valve, still anchored to its delivery catheter, reload it and re-implant it, but to no avail. The prosthesis would not shrink to fit into the 18F sheath. We also injected cold water through the sheath's side port in an attempt to shrink the valve, as per the manufacturer's recommendations. Forceful and persistent manipulation led to full prosthesis deployment. A second CV was decided to be implanted. We passed the delivery system of the second valve through the first valve (‘valve-through’ technique) (Fig. 1a) and it was successfully implanted. An aortography revealed compromised blood flow to the left common iliac artery, as its ostium was occluded from the “skirt” of the lodged CV (Fig. 1b). An attempt to retrieve the lodged prosthesis with an Amplatz GooseNeck Snare (ev3, Plymouth, MN) catheter was unsuccessful. The patient's left femoral pulse was absent and the left lower limb was cyanotic, so the patient was rushed to the operating room. A vascular surgeon made an abdominal incision and the lodged valve was ⁎ Corresponding author at: Athens University Medical School, Hippokration Hospital, Vasilissis Sofias 114, 115 28, Athens, Greece. Tel.: + 30 107782446; fax: + 30 107784590. E-mail address: [email protected] (D. Tousoulis). 0167-5273/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2012.09.164
removed through a small incision in the abdominal aorta. Right before removing it, the surgeon rinsed the area with cold water in order to shrink it (Fig. 2a, b). The patient was discharged 10 days post TAVI with no further complications. At one-month follow-up the patient was in NYHA I state, and echocardiography revealed mild paravalvular aortic regurgitation. Valve dislocation and embolization has been described for both balloon and self-expandable valves. Most frequently the displacement or embolization can be managed in the catheterization laboratory. Devices implanted too deep in the left ventricle can be pulled up back by a snare catheter, and underdeployed valves may become fully deployed with post balloon dilation. Furthermore, the prostheses can be retrieved through the introducing sheath and reloaded on the delivery catheter. Depending on operator's preference and aortic valve function, a second valve may be implanted. All our attempts to remove the valve percutaneously were unsuccessful, and a surgical solution was required. It is of great importance that each TAVI procedure is performed in an experienced center with stand-by cardiovascular surgical back-up [1–4]. Avoiding situations in which dislocation might occur is also important. Patient selection and screening are crucial for a successful TAVI. Furthermore, the operators after the deployment of a CV should check that the delivery system is not attached to the valve's hooks that could lead to an accidental valve dislocation. The CV prosthesis can be maneuvered when partially deployed, a feature that is of great assistance during the deployment of the valve. In this case, material failure led to an unsuccessful attempt to remove the CV. Manipulation of the prosthesis, while partially deployed, might have led to the hinge-nitinol frame material failing and causing the release of the valve at the aorto-iliac bifurcation. Had it lodged higher in the abdominal aorta, we would have left it there since favorable midterm experience exists [5]. However, in our specific case, the malpositioned prosthesis was causing critical left limb ischemia, and therefore it needed to be removed immediately. This was successfully performed in the operating theater. In conclusion, it is critical for TAVI to be performed in experienced centers with stand-by cardiovascular surgical back-up. Acknowledgments The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology.
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G. Latsios et al. / International Journal of Cardiology 164 (2013) e27–e28
Fig. 1. a: Delivery system with the 2nd CoreValve passing through the right common iliac artery (1) and lodged 1st CoreValve (2). b: Angiography of the abdominal aorta demonstrating normal blood flow in the right common iliac artery (1) and compromised blood flow through the left common iliac artery (2).
Fig. 2. a: At the operating theater, the bulging right common iliac artery was observed with the lodged 1st CoreValve inside it. b: Retrieved 1st CoreValve.
References [1] Al Ali AM, Altwegg L, Horlick EM, et al. Prevention and management of transcatheter balloon-expandable aortic valve malposition. Catheter Cardiovasc Interv 2008;72(4):573-8. [2] Fairbairn TA, Greenwood JP, Blackman DJ. Multiple cerebral emboli following dislocation and retraction of a partially deployed corevalve prosthesis during transcatheter aortic valve implantation. Catheter Cardiovasc Interv 2011 Sep 27, doi:10.1002/ccd.23308.
[3] Geisbusch S, Bleiziffer S, Mazzitelli D, Ruge H, Bauernschmitt R, Lange R. Incidence and management of CoreValve dislocation during transcatheter aortic valve implantation. Circulation 2010;3(6):531-6. [4] Tuzcu EM. Transcatheter aortic valve replacement malposition and embolization: innovation brings solutions also new challenges. Catheter Cardiovasc Interv 2008;72(4):579-80. [5] Gerckens U, Latsios G, Mueller R, et al. Procedural and mid-term results in patients with aortic stenosis treated with implantation of 2 (in-series) CoreValve prostheses in 1 procedure. J Am Coll Cardiol 2011;3(2):244-50.
Contents lists available at SciVerse ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Prosthetic aortic valve removal from the abdominal aorta after successful “valve-through” TAVI George Latsios a, Konstantinos Toutouzas a, Dimitris Tousoulis a,⁎, Konstantinos Stathogiannis a, Costas Tentolouris a, Andreas Synetos a, Konstantinos Filis b, Christodoulos Stefanadis a a b
First Cardiology Department of Athens Medical School, Hippokration Hospital, Athens, Greece Department of Vascular Surgery, Athens Medical School, Athens, Greece
a r t i c l e
i n f o
Article history: Received 13 September 2012 Accepted 25 September 2012 Available online 12 October 2012 Keywords: Aortic stenosis Aortic valve TAVI Core valve
Trans-catheter aortic valve implantation (TAVI) is the treatment of choice for high-risk inoperable patients with severe symptomatic aortic valve stenosis (AVS). An 85-year-old male patient with severe symptomatic AVS was referred for TAVI; with a logistic EuroSCORE of 20.21%. During its deployment, the 29 mm CoreValve (CV) prosthesis was ejected out of its intended anatomic position, in a supra-annular level. Because that happened at two-thirds of the deployment, we decided to retract the valve, still anchored to its delivery catheter, reload it and re-implant it, but to no avail. The prosthesis would not shrink to fit into the 18F sheath. We also injected cold water through the sheath's side port in an attempt to shrink the valve, as per the manufacturer's recommendations. Forceful and persistent manipulation led to full prosthesis deployment. A second CV was decided to be implanted. We passed the delivery system of the second valve through the first valve (‘valve-through’ technique) (Fig. 1a) and it was successfully implanted. An aortography revealed compromised blood flow to the left common iliac artery, as its ostium was occluded from the “skirt” of the lodged CV (Fig. 1b). An attempt to retrieve the lodged prosthesis with an Amplatz GooseNeck Snare (ev3, Plymouth, MN) catheter was unsuccessful. The patient's left femoral pulse was absent and the left lower limb was cyanotic, so the patient was rushed to the operating room. A vascular surgeon made an abdominal incision and the lodged valve was ⁎ Corresponding author at: Athens University Medical School, Hippokration Hospital, Vasilissis Sofias 114, 115 28, Athens, Greece. Tel.: + 30 107782446; fax: + 30 107784590. E-mail address: [email protected] (D. Tousoulis). 0167-5273/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2012.09.164
removed through a small incision in the abdominal aorta. Right before removing it, the surgeon rinsed the area with cold water in order to shrink it (Fig. 2a, b). The patient was discharged 10 days post TAVI with no further complications. At one-month follow-up the patient was in NYHA I state, and echocardiography revealed mild paravalvular aortic regurgitation. Valve dislocation and embolization has been described for both balloon and self-expandable valves. Most frequently the displacement or embolization can be managed in the catheterization laboratory. Devices implanted too deep in the left ventricle can be pulled up back by a snare catheter, and underdeployed valves may become fully deployed with post balloon dilation. Furthermore, the prostheses can be retrieved through the introducing sheath and reloaded on the delivery catheter. Depending on operator's preference and aortic valve function, a second valve may be implanted. All our attempts to remove the valve percutaneously were unsuccessful, and a surgical solution was required. It is of great importance that each TAVI procedure is performed in an experienced center with stand-by cardiovascular surgical back-up [1–4]. Avoiding situations in which dislocation might occur is also important. Patient selection and screening are crucial for a successful TAVI. Furthermore, the operators after the deployment of a CV should check that the delivery system is not attached to the valve's hooks that could lead to an accidental valve dislocation. The CV prosthesis can be maneuvered when partially deployed, a feature that is of great assistance during the deployment of the valve. In this case, material failure led to an unsuccessful attempt to remove the CV. Manipulation of the prosthesis, while partially deployed, might have led to the hinge-nitinol frame material failing and causing the release of the valve at the aorto-iliac bifurcation. Had it lodged higher in the abdominal aorta, we would have left it there since favorable midterm experience exists [5]. However, in our specific case, the malpositioned prosthesis was causing critical left limb ischemia, and therefore it needed to be removed immediately. This was successfully performed in the operating theater. In conclusion, it is critical for TAVI to be performed in experienced centers with stand-by cardiovascular surgical back-up. Acknowledgments The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology.
e28
G. Latsios et al. / International Journal of Cardiology 164 (2013) e27–e28
Fig. 1. a: Delivery system with the 2nd CoreValve passing through the right common iliac artery (1) and lodged 1st CoreValve (2). b: Angiography of the abdominal aorta demonstrating normal blood flow in the right common iliac artery (1) and compromised blood flow through the left common iliac artery (2).
Fig. 2. a: At the operating theater, the bulging right common iliac artery was observed with the lodged 1st CoreValve inside it. b: Retrieved 1st CoreValve.
References [1] Al Ali AM, Altwegg L, Horlick EM, et al. Prevention and management of transcatheter balloon-expandable aortic valve malposition. Catheter Cardiovasc Interv 2008;72(4):573-8. [2] Fairbairn TA, Greenwood JP, Blackman DJ. Multiple cerebral emboli following dislocation and retraction of a partially deployed corevalve prosthesis during transcatheter aortic valve implantation. Catheter Cardiovasc Interv 2011 Sep 27, doi:10.1002/ccd.23308.
[3] Geisbusch S, Bleiziffer S, Mazzitelli D, Ruge H, Bauernschmitt R, Lange R. Incidence and management of CoreValve dislocation during transcatheter aortic valve implantation. Circulation 2010;3(6):531-6. [4] Tuzcu EM. Transcatheter aortic valve replacement malposition and embolization: innovation brings solutions also new challenges. Catheter Cardiovasc Interv 2008;72(4):579-80. [5] Gerckens U, Latsios G, Mueller R, et al. Procedural and mid-term results in patients with aortic stenosis treated with implantation of 2 (in-series) CoreValve prostheses in 1 procedure. J Am Coll Cardiol 2011;3(2):244-50.