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Rescue TAVI in bicuspid aortic stenosis and aortic inflammation
cor et vasa 59 (2017) e57–e59
Available online at www.sciencedirect.com
ScienceDirect journal homepage: http://www.elsevier.com/locate/crvasa
Images in cardiology – Special issue: Structural heart disease – Aortic and mitral
Rescue TAVI in bicuspid aortic stenosis and aortic inflammation Josef Bis a,*, Josef Stasek a, Jaroslav Dusek a, Miroslav Brtko b, Pavel Polansky b, Andrej Myjavec b a
1st Department of Cardioangiology, Faculty of Medicine in Hradec Králové, Charles University in Prague and University Hospital Hradec Kralove, Sokolska 581, Hradec Kralove 50005, Czech Republic b Department of Cardiac Surgery, Faculty of Medicine in Hradec Králové, Charles University in Prague and University Hospital Hradec Kralove, Sokolska 581, Hradec Kralove 50005, Czech Republic
article info Article history: Received 14 December 2016 Accepted 12 January 2017 Available online 20 February 2017 Keywords: Bicuspid aortic stenosis Aortic inflammation TAVI Edwards Sapien S3
We present the case of a 63-year-old man suffering from dyspnoea on exertion, NYHA III. On TOE, we found bicuspid aortic valve disease with severe stenosis – gradient 82/ 51 mmHg, AVA 0.6 cm2, AVAi 0.3 cm2/m2, aortic regurgitation 2–3/4, EF 60%. Initially, the patient was referred for surgical aortic valve replacement, but the procedure was not
performed because of the thickening and infiltration of aortic wall and pericardium. Further examination verified ANCA positive autoimmune inflammation of the aorta. At the time of ongoing investigations, the patient got progressively worse with dyspnoea and had decrease of EF to 30%. His valve disease had to be treated immediately. The PET/CT revealed a thickening of ascending aorta, aortic arch and descending aorta up to coeliac trunk with active infiltration up to 11 mm. This finding, we suspected, was associated with the increased risk of injury during the insertion of the valve. Aortic valve was bicuspid with bulky calcifications; moreover, the annulus was eccentric, and the diameters by TOE were 22 mm 26 mm (452–464 mm2) and 21 mm 26 mm (437 mm2) by CT. Additional risk for the patient represents dilatation of the ascending aorta to 49 mm (Figs. 1 and 2). We decided for direct implantation of Edwards Sapien S3 26 mm valve, without predilatation. The procedure was performed under conscious sedation, without complications and no paravalvular leak. The final echo gradient was 17/ 9 mmHg, and EF imminently increased to 45%. The patient was discharged 2 days after the procedure (Figs. 3–5).
* Corresponding author. E-mail address: [email protected] (J. Bis). http://dx.doi.org/10.1016/j.crvasa.2017.01.009 0010-8650/© 2017 The Czech Society of Cardiology. Published by Elsevier Sp. z o.o. All rights reserved.
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cor et vasa 59 (2017) e57–e59
Fig. 2 – Bicuspid aortic valve with severe calcification in cusps: (a) 2D TEE and (b) 3D TEE.
Fig. 1 – (a and b) CT scan of ascending aorta and arch. White arrows mark the infiltration by autoimmune inflammation.
Fig. 3 – Virtual reconstruction of aortic root and coronary ostia for TAVI navigation. Proposed optimal angulation for TAVI placement is LAO 148/CAUD 118.
cor et vasa 59 (2017) e57–e59
e59
Conflict of interest None declared.
Ethical statement Authors state that the research was conducted according to ethical standards.
Informed consent I declare, that informed consent requirements do not apply to this manuscript. Fig. 4 – Optimal perpendicular placement of Edwards Sapien S3 valve in aortic annulus.
Funding body Financially supported by project PROGRES Q40/03.
Fig. 5 – Post-TAVI with Edwards Sapien S3 26 valve, without any regurgitation at angiography.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: http://www.elsevier.com/locate/crvasa
Images in cardiology – Special issue: Structural heart disease – Aortic and mitral
Rescue TAVI in bicuspid aortic stenosis and aortic inflammation Josef Bis a,*, Josef Stasek a, Jaroslav Dusek a, Miroslav Brtko b, Pavel Polansky b, Andrej Myjavec b a
1st Department of Cardioangiology, Faculty of Medicine in Hradec Králové, Charles University in Prague and University Hospital Hradec Kralove, Sokolska 581, Hradec Kralove 50005, Czech Republic b Department of Cardiac Surgery, Faculty of Medicine in Hradec Králové, Charles University in Prague and University Hospital Hradec Kralove, Sokolska 581, Hradec Kralove 50005, Czech Republic
article info Article history: Received 14 December 2016 Accepted 12 January 2017 Available online 20 February 2017 Keywords: Bicuspid aortic stenosis Aortic inflammation TAVI Edwards Sapien S3
We present the case of a 63-year-old man suffering from dyspnoea on exertion, NYHA III. On TOE, we found bicuspid aortic valve disease with severe stenosis – gradient 82/ 51 mmHg, AVA 0.6 cm2, AVAi 0.3 cm2/m2, aortic regurgitation 2–3/4, EF 60%. Initially, the patient was referred for surgical aortic valve replacement, but the procedure was not
performed because of the thickening and infiltration of aortic wall and pericardium. Further examination verified ANCA positive autoimmune inflammation of the aorta. At the time of ongoing investigations, the patient got progressively worse with dyspnoea and had decrease of EF to 30%. His valve disease had to be treated immediately. The PET/CT revealed a thickening of ascending aorta, aortic arch and descending aorta up to coeliac trunk with active infiltration up to 11 mm. This finding, we suspected, was associated with the increased risk of injury during the insertion of the valve. Aortic valve was bicuspid with bulky calcifications; moreover, the annulus was eccentric, and the diameters by TOE were 22 mm 26 mm (452–464 mm2) and 21 mm 26 mm (437 mm2) by CT. Additional risk for the patient represents dilatation of the ascending aorta to 49 mm (Figs. 1 and 2). We decided for direct implantation of Edwards Sapien S3 26 mm valve, without predilatation. The procedure was performed under conscious sedation, without complications and no paravalvular leak. The final echo gradient was 17/ 9 mmHg, and EF imminently increased to 45%. The patient was discharged 2 days after the procedure (Figs. 3–5).
* Corresponding author. E-mail address: [email protected] (J. Bis). http://dx.doi.org/10.1016/j.crvasa.2017.01.009 0010-8650/© 2017 The Czech Society of Cardiology. Published by Elsevier Sp. z o.o. All rights reserved.
e58
cor et vasa 59 (2017) e57–e59
Fig. 2 – Bicuspid aortic valve with severe calcification in cusps: (a) 2D TEE and (b) 3D TEE.
Fig. 1 – (a and b) CT scan of ascending aorta and arch. White arrows mark the infiltration by autoimmune inflammation.
Fig. 3 – Virtual reconstruction of aortic root and coronary ostia for TAVI navigation. Proposed optimal angulation for TAVI placement is LAO 148/CAUD 118.
cor et vasa 59 (2017) e57–e59
e59
Conflict of interest None declared.
Ethical statement Authors state that the research was conducted according to ethical standards.
Informed consent I declare, that informed consent requirements do not apply to this manuscript. Fig. 4 – Optimal perpendicular placement of Edwards Sapien S3 valve in aortic annulus.
Funding body Financially supported by project PROGRES Q40/03.
Fig. 5 – Post-TAVI with Edwards Sapien S3 26 valve, without any regurgitation at angiography.