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Successful Treatment by Transcatheter Aortic Valve Implantation of Severe Aortic Regurgitation in a Patient with Ascending Aorta Prosthesis
CLINICAL SPOTLIGHT
Clinical Spotlight
Successful Treatment by Transcatheter Aortic Valve Implantation of Severe Aortic Regurgitation in a Patient with Ascending Aorta Prosthesis Marco Luciano Rossi, MD ∗ , Roberto Bocchi, MD, Cristina Barbaro, MD, Paolo Pagnotta, MD, Marco Mennuni, MD, Dennis Zavalloni, MD, Gabriele Gasparini, MD and Patrizia Presbitero, MD Department of Invasive Cardiology, Istituto Clinico Humanitas, Rozzano, Milan, Italy
Severe aortic regurgitation (AR), when intervention is required, is managed by surgical aortic valve replacement (SAVR). Recently, transcatheter aortic valve replacement (TAVR) for severe aortic stenosis (AS) has shown non-inferiority to SAVR and superiority to medical management. TAVR could be a valid “off label” option to treat severe AR for patients unsuitable for SAVR due to their high surgical risk. Among aortic pathologies leading to severe AR, those involving the aortic root are considered as high risk procedures and thus prohibit TAVR. For these reasons TAVR is not an option for severe AR due to concomitant aortic root dilatation and degeneration. We report a successful case of TAVR for severe AR due to dilatation of degenerated tract of aortic root. (Heart, Lung and Circulation 2013;22:383–385) © 2012 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved. Keywords. Aortic valve replacement; Ascending aorta prosthesis; Aneurysm
Introduction
T
AVR has recently proven to be a valid treatment for severe AS in patients with prohibitive or high surgical risk [1,2]. On the other hand TAVR is not considered a valid option in inoperable patients with severe AR due to concomitant aortic root dilatation and degeneration. We hereby describe a successful case of TAVR for severe AR due to dilation of degenerated tract of aortic root and the presence of pseudoaneurysm in a patient with history of aneurysmectomy of ascending aorta for whom conventional surgery was not feasible.
Case Report An 80 year-old woman was admitted for progressive dyspnoea, ortopnoea and peripheral oedema (NYHA 3). The patient had a history of aneurysmectomy of abdominal aortic aneurism in 2005 and aneurysmectomy of ascending aorta with 26 mm diameter dacron tube placement and concomitant by-pass graft AMIs-LAD in Received 7 September 2012; received in revised form 12 October 2012; accepted 15 October 2012; available online 16 November 2012 ∗
Corresponding author at: Department of Invasive Cardiology, Istituto Clinico Humanitas, Via Manzoni 56, 20089 Rozzano, Milan, Italy. Tel.: +39 02 82243601; fax: +39 02 82243690. E-mail address: marco [email protected] (M.L. Rossi).
2007. Echocardiography showed a depressed left ventricular ejection fraction of 45% and severe aortic regurgitation caused by dilation of aortic root of 47 mm. Computed tomography (CT) and transoesophageal echocardiography (TEE) confirmed the dilatation of aortic root and arch and revealed the presence of pseudoaneurysm of 3.5 cm × 2 cm to the proximal anastomosis on the posterior wall of ascending aorta close to left main coronary artery (Fig. 1, Panel A–D). Indeed, CT scan showed the presence of right contracted kidney and severe kyphoscoliosis. After a multidisciplinary evaluation, surgical correction of the pseudoaneurysm and aortic regurgitation was excluded because of high predicted operative mortality (Logistic EUROSCORE=80; EUROSCORE II 26) and medical management was decided. The patient was discharged in NYHA class III. In the next six months she was re-hospitalised twice for acute pulmonary oedema due to severe aortic regurgitation. Finally, transcatheter aortic valve replacement (TAVR) was considered. TAVR was performed under general anaesthesia and TEE guidance, via transfemoral approach, using a 29 mm Medtronic Core Valve prosthesis without complications (Fig. 2). The post-procedure TEE control showed mild aortic regurgitation (1+). Patient was discharged at day 6. She has had an uncomplicated course since then, remaining in NYHA class I–II (one year follow-up). After six months a CT scan revealed the partial thrombosis of pseudoaneurysm (Fig. 1 Panel E).
© 2012 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved.
1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2012.10.002
CLINICAL SPOTLIGHT
384
Rossi et al. TAVR for AR in Degenerated Ascending Aorta Prosthesis
Heart, Lung and Circulation 2013;22:383–385
Figure 1. (Panels A–C) TEE before TAVR documenting the presence of pseudoaneurysm at the proximal anastomosis on the posterior wall of ascending aorta near to left main (arrow). (Panel D) CT scan before TAVR. The pseudoaneurysm at the proximal anastomosis on the posterior wall is indicated by the arrow. (Panel E) Partial thrombosis of pseudoaneurysm (arrow) at the CT scan performed 6 months after TAVR.
Rossi et al. TAVR for AR in Degenerated Ascending Aorta Prosthesis
385
rapid pacing in order to avoid valve ejection during implantation. In this particular case the presence of a prosthetic tube allowed to hold the CoreValve stent anchoring the valve without damage to the degenerated aortic tract. Moreover, the presence of the CoreValve covering the pseudoaneurysm contributed to the partial thrombosis and possibly to the stabilisation of this site at high risk of sudden rupture.
Conclusion This case report shows that TAVR may be considered as a valid option to treat severe aortic regurgitation also in the presence of a prosthetic tube in a degenerated tract of ascending aorta when conventional surgery is not feasible.
References
Figure 2. Deployment of the Medtronic Core Valve.
Discussion In this case the large aortic annulus diameter, the presence of the pseudoaneurysm and the absence of aortic valve calcifications were the anatomical aspects that made the procedure very challenging. As already described [3] the CoreValve deploying technique in case of AR required
[1] Smith CR, Leon MB, Mack MJ, Miller DC, Moses JW, Svensson LG, et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med 2011;364: 2187–98. [2] Leon MB, Smith CR, Mack M, Miller DC, Moses JW, Svensson LG, et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med 2010;363:1597–607. [3] Yeow WL, Roberts-Thompson P, Shetty S, Yong G. Expanding role for transcatheter aortic valve implantation of a Medtronic Core Valve for severe aortic regurgitation. Heart Lung Circ 2012;25(April) [Epub ahead of print].
CLINICAL SPOTLIGHT
Heart, Lung and Circulation 2013;22:383–385
Clinical Spotlight
Successful Treatment by Transcatheter Aortic Valve Implantation of Severe Aortic Regurgitation in a Patient with Ascending Aorta Prosthesis Marco Luciano Rossi, MD ∗ , Roberto Bocchi, MD, Cristina Barbaro, MD, Paolo Pagnotta, MD, Marco Mennuni, MD, Dennis Zavalloni, MD, Gabriele Gasparini, MD and Patrizia Presbitero, MD Department of Invasive Cardiology, Istituto Clinico Humanitas, Rozzano, Milan, Italy
Severe aortic regurgitation (AR), when intervention is required, is managed by surgical aortic valve replacement (SAVR). Recently, transcatheter aortic valve replacement (TAVR) for severe aortic stenosis (AS) has shown non-inferiority to SAVR and superiority to medical management. TAVR could be a valid “off label” option to treat severe AR for patients unsuitable for SAVR due to their high surgical risk. Among aortic pathologies leading to severe AR, those involving the aortic root are considered as high risk procedures and thus prohibit TAVR. For these reasons TAVR is not an option for severe AR due to concomitant aortic root dilatation and degeneration. We report a successful case of TAVR for severe AR due to dilatation of degenerated tract of aortic root. (Heart, Lung and Circulation 2013;22:383–385) © 2012 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved. Keywords. Aortic valve replacement; Ascending aorta prosthesis; Aneurysm
Introduction
T
AVR has recently proven to be a valid treatment for severe AS in patients with prohibitive or high surgical risk [1,2]. On the other hand TAVR is not considered a valid option in inoperable patients with severe AR due to concomitant aortic root dilatation and degeneration. We hereby describe a successful case of TAVR for severe AR due to dilation of degenerated tract of aortic root and the presence of pseudoaneurysm in a patient with history of aneurysmectomy of ascending aorta for whom conventional surgery was not feasible.
Case Report An 80 year-old woman was admitted for progressive dyspnoea, ortopnoea and peripheral oedema (NYHA 3). The patient had a history of aneurysmectomy of abdominal aortic aneurism in 2005 and aneurysmectomy of ascending aorta with 26 mm diameter dacron tube placement and concomitant by-pass graft AMIs-LAD in Received 7 September 2012; received in revised form 12 October 2012; accepted 15 October 2012; available online 16 November 2012 ∗
Corresponding author at: Department of Invasive Cardiology, Istituto Clinico Humanitas, Via Manzoni 56, 20089 Rozzano, Milan, Italy. Tel.: +39 02 82243601; fax: +39 02 82243690. E-mail address: marco [email protected] (M.L. Rossi).
2007. Echocardiography showed a depressed left ventricular ejection fraction of 45% and severe aortic regurgitation caused by dilation of aortic root of 47 mm. Computed tomography (CT) and transoesophageal echocardiography (TEE) confirmed the dilatation of aortic root and arch and revealed the presence of pseudoaneurysm of 3.5 cm × 2 cm to the proximal anastomosis on the posterior wall of ascending aorta close to left main coronary artery (Fig. 1, Panel A–D). Indeed, CT scan showed the presence of right contracted kidney and severe kyphoscoliosis. After a multidisciplinary evaluation, surgical correction of the pseudoaneurysm and aortic regurgitation was excluded because of high predicted operative mortality (Logistic EUROSCORE=80; EUROSCORE II 26) and medical management was decided. The patient was discharged in NYHA class III. In the next six months she was re-hospitalised twice for acute pulmonary oedema due to severe aortic regurgitation. Finally, transcatheter aortic valve replacement (TAVR) was considered. TAVR was performed under general anaesthesia and TEE guidance, via transfemoral approach, using a 29 mm Medtronic Core Valve prosthesis without complications (Fig. 2). The post-procedure TEE control showed mild aortic regurgitation (1+). Patient was discharged at day 6. She has had an uncomplicated course since then, remaining in NYHA class I–II (one year follow-up). After six months a CT scan revealed the partial thrombosis of pseudoaneurysm (Fig. 1 Panel E).
© 2012 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved.
1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2012.10.002
CLINICAL SPOTLIGHT
384
Rossi et al. TAVR for AR in Degenerated Ascending Aorta Prosthesis
Heart, Lung and Circulation 2013;22:383–385
Figure 1. (Panels A–C) TEE before TAVR documenting the presence of pseudoaneurysm at the proximal anastomosis on the posterior wall of ascending aorta near to left main (arrow). (Panel D) CT scan before TAVR. The pseudoaneurysm at the proximal anastomosis on the posterior wall is indicated by the arrow. (Panel E) Partial thrombosis of pseudoaneurysm (arrow) at the CT scan performed 6 months after TAVR.
Rossi et al. TAVR for AR in Degenerated Ascending Aorta Prosthesis
385
rapid pacing in order to avoid valve ejection during implantation. In this particular case the presence of a prosthetic tube allowed to hold the CoreValve stent anchoring the valve without damage to the degenerated aortic tract. Moreover, the presence of the CoreValve covering the pseudoaneurysm contributed to the partial thrombosis and possibly to the stabilisation of this site at high risk of sudden rupture.
Conclusion This case report shows that TAVR may be considered as a valid option to treat severe aortic regurgitation also in the presence of a prosthetic tube in a degenerated tract of ascending aorta when conventional surgery is not feasible.
References
Figure 2. Deployment of the Medtronic Core Valve.
Discussion In this case the large aortic annulus diameter, the presence of the pseudoaneurysm and the absence of aortic valve calcifications were the anatomical aspects that made the procedure very challenging. As already described [3] the CoreValve deploying technique in case of AR required
[1] Smith CR, Leon MB, Mack MJ, Miller DC, Moses JW, Svensson LG, et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med 2011;364: 2187–98. [2] Leon MB, Smith CR, Mack M, Miller DC, Moses JW, Svensson LG, et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med 2010;363:1597–607. [3] Yeow WL, Roberts-Thompson P, Shetty S, Yong G. Expanding role for transcatheter aortic valve implantation of a Medtronic Core Valve for severe aortic regurgitation. Heart Lung Circ 2012;25(April) [Epub ahead of print].
CLINICAL SPOTLIGHT
Heart, Lung and Circulation 2013;22:383–385