- Email: [email protected]
Transaortic Valve-in-Valve Implantation After Previous Aortic Root Homograft
1718
CASE REPORT IHLBERG ET AL TAVI VIV IMPLANTATION FOR AORTIC ROOT HOMOGRAFT
FEATURE ARTICLES
wound to the chest can have a wide range of clinical presentations, from no intrathoracic injury to extensive life-threatening great vessel damage, as outlined in this case. Injury to the pulmonary artery alone can be complex, albeit amenable to successful surgical repair [2]. In this case, there was additional injury to the inferomedial aspect of the aortic arch, which in itself could be fatal [3]. TTE to exclude a pericardial effusion can be a useful tool; however, it was a false-negative finding in this case. Negative findings, although initially reassuring, must not be misleading particularly in a case with penetrating trauma to the thoracic box. CT scans can aid operative planning and provide information on the location of the injury [4]. In this case, the CT scans provided an accurate location of the aortic arch injury, but were only suggestive of a pulmonary artery injury. This patient had no features of hemoptysis, which could be an indication of PA injury [2]. There have been reports of delayed cardiac tamponade following initial negative investigations [5]; therefore, a high index of suspicion for injury must be maintained in any patient with a penetrating injury to the thorax. The potential for a posterior right PA injury was recognized perioperatively by extending the anterior right PA injury. This could only be repaired by extension of the anterior tear. Transection of the aorta provided necessary access, to visualize and repair both the anterior and posterior walls of the right PA. The use of CPB facilitated this repair, and transection of the aorta should be considered when faced with extensive injuries to the pulmonary artery. This case illustrates the rapid decline in hemodynamic stability, resulting in cardiac arrest, associated with such an injury. This patient’s reasonable clinical status following initial resuscitation was falsely reassuring. In retrospect, the nature of the injury, initial hypotensive presentation, metabolic acidosis, chest radiographic findings, and initial CT thorax scan provided sufficient cause for earlier surgical exploration. Median sternotomy allowed establishment of CPB, HCA, and cardioplegic arrest and provided the best access for repair of the aortic arch and right PA. If this patient had remained cardiovascularly unstable and then arrested, a more utilized approach, of an urgent emergency room anterior bilateral thoracotomy may have been indicated [6]. This approach, although useful in most circumstances of penetrating thoracic injury, would not have allowed control of the bleeding, institution of central CPB, and surgical repair, because of the nature of these injuries. Correct interpretation of the CT scan facilitated the correct operative strategy and environment for this patient. A single stab injury to the thorax can cause extensive intrathoracic damage to the great vessels and is associated with morbid consequences. A high index of suspicion for intrathoracic injury should remain despite initial cardiovascular stability and early negative investigative findings. This suspicion should prompt further investigations and early surgical exploration as required. © 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2012;94:1718 –21
References 1. Fulton JO, de Groot KM, Buckels NJ, von Oppell UO. Penetrating injuries involving the intrathoracic great vessels. S Afr J Surg 1997;35:82– 6. 2. Deneuville M. Injury of the pulmonary artery and its branches due to penetrating chest trauma. Ann Vasc Surg 2000;14:463–7. 3. Buchan K, Robbs JV. Surgical management of penetrating mediastinal arterial trauma. Eur J Cardiothorac Surg 1995;9: 90 – 4. 4. Pereira SJ, Narrod JA. Repair of right pulmonary artery transection after blunt trauma. Ann Thorac Surg 2009;87: 939 – 40. 5. Mechem CC, Alam GA. Delayed cardiac tamponade in a patient with penetrating chest trauma. J Emerg Med 1997;15: 31–3. 6. Hunt PA, Greaves I, Owens WA. Emergency thoracotomy in thoracic trauma-a review. Injury 2006;37:1–19.
Transaortic Valve-in-Valve Implantation After Previous Aortic Root Homograft Leo Ihlberg, MD, PhD, Antero Sahlman, MD, Juha Sinisalo, MD, Janne Rapola, MD, PhD, and Mika Laine, MD, PhD Departments of Cardiothoracic Surgery and Cardiology, Helsinki University Hospital, Helsinki, Finland
Catheter-based valve implantation techniques are becoming a viable option in various clinical situations to replace difficult redo open heart surgical procedures. This is a report of a first, to our knowledge, successful valve-in-valve (VinV) transcatheter aortic valve implantation (TAVI) into a homograft through the transaortic (TAo) access route using an Edwards SAPIEN valve prosthesis (Edwards Lifesciences, LLC, Irvine, CA) in a patient with poor left ventricular function and generalized severe atherosclerosis. (Ann Thorac Surg 2012;94:1718 –21) © 2012 by The Society of Thoracic Surgeons
R
epeated aortic root operations for a failed homograft can be a technically challenging undertaking, especially if the whole aortic root needs to be replaced. Associated risks could even make a conventional open surgical approach prohibitive. Transcatheter aortic valve implantation (TAVI) is a new treatment modality that could potentially be used for this patient group. Herein we report the first, to our knowledge, valve-in-valve (VinV) TAVI into a homograft through the transaortic
Accepted for publication March 29, 2012. Address correspondence to Dr Ihlberg, Department of Cardiothoracic Surgery, Helsinki University Hospital, PO Box 340, FI-00029 Helsinki, Finland; e-mail: [email protected].
Dr Ihlberg discloses that he has a financial relationship with Edwards Lifesciences.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2012.03.111
Fig 1. Preoperative 3-dimensional multidetector computed tomography (MDCT) angiographic reconstruction depicts a complete circumferential calcification of the aortic root homograft. The distal ascending aorta is relatively free of disease.
(TAo) access route using an Edwards SAPIEN valve prosthesis (Edwards Lifesciences, Irvine, CA) in a patient with poor left ventricular function and generalized atherosclerosis. In 2001, a now 65-year-old man underwent an aortic root reconstruction with a homograft for native valve endocarditis. The anterior mitral leaflet of the homograft was used as a patch for a new fibrous body between the aortic and mitral valves. After adequate antimicrobial treatment, the patient recovered without any signs of reinfection. His other medical comorbidities included an asymptomatic chronic hepatitis C infection and severe lower extremity arteriopathy. Since 2009, a gradual worsening in his exercise tolerance had been noted and in June 2011 he presented in New York Heart Association class IV congestive heart failure and pulmonary edema. Moderate aortic stenosis was demonstrated by the transthoracic cardiac echocardiogram with peak and mean transvalvular gradients of 29 mm Hg and 15 mmHg, respectively. The valve opening area was 0.7 cm2. The aortic regurgitation was graded as severe. Left ventricular function was impaired with an ejection fraction of 20% and end-diastolic diameter of 65 mm. Severe pulmonary hypertension of 60 mm Hg was present. Coronary angiography revealed stenosis of 90% in his hypoplastic right coronary artery. Multidetector computed tomography (MDCT) angiography showed the aortic root homograft to be heavily calcified (Fig 1) on the valve leaflets and also circumferentially the entire length of the wall. The distal ascending aorta was relatively free of disease. A chronic total occlusion of the right iliac-femoral vessel and a severe calcification and narrowing of the lumen on the left side was also noted.
CASE REPORT IHLBERG ET AL TAVI VIV IMPLANTATION FOR AORTIC ROOT HOMOGRAFT
1719
His logistic EuroSCORE for conventional surgical treatment was 43.5%. The patient’s case was discussed in a multidisciplinary meeting and a joint decision to proceed with TAVI was made. The procedure was performed using general anesthesia with both fluoroscopic and transesophageal echocardiographic guidance using a 29-mm Edwards SAPIEN Transcatheter Heart Valve (Edwards Lifesciences). The TAo-TAVI was performed as previously described [1]. In brief, a temporary right ventricular pacemaker was placed through the right jugular vein. The left common femoral artery was cannulated with a 6F multipurpose MPA catheter (Boston Scientific Corp, Natick, MA). Access to the distal ascending aorta was gained through an upper partial J-shaped resternotomy to the right second intercostal space. Two pledgeted purse-string sutures were placed at the selected spot, which was chosen both by identifying a calcific-free spot in the preoperative MDCT angiogram and directly palpating the aorta. A direct needle puncture was performed to introduce a soft wire and a 6F multipurpose MPA catheter (Boston Scientific Corp). After the aortic valve was crossed with the wire, a preshaped Super Stiff Amplatz guidewire (Boston Scientific Corp) was placed into the left ventricle followed by insertion of an Ascendra sheath (Edwards Lifesciences) into the ascending aorta. First, a balloon valvuloplasty was performed with a 20 ⫻ 30 mm balloon followed by a successful implantation of a 29-mm Edwards SAPIEN valve (Edwards Lifesciences) into the desired position. These procedures were both performed during short bursts of rapid ventricular pacing at 180 beats/min. Optimal valve position and function could be demonstrated by both transesophageal echocardiography and aortic root angiography. He made an uneventful postoperative recovery and was discharged home 5 days after the procedure. At 6 months after the Tao-TAVI, he presented with significant clinical improvement and is in New York Heart Association class II. By transesophageal echocardiography, the left ventricular function is seen to have improved significantly and is now 40%. The respective mean and peak transvalvular gradients are 5 and 9 mm Hg, respectively, with no aortic regurgitation.
Comment Homograft aortic valve replacement using the freestanding root technique with reimplantation of the coronary arteries was introduced some 30 years ago [2]. Homografts however are of limited durability because of late degenerative valve failure and dense calcification, as with all other bioprosthetic aortic valve substitutes. Reoperation of the aortic valve can be performed in a subset of patients with insertion of a new valve within the previous root, but in cases of more extensive calcification, the only option is to take down the calcified homograft root and replace it again completely [3]. This is technically demanding and has led to significant perioperative mortality and morbidity, even in patients deemed fit for surgical intervention [3, 4].
FEATURE ARTICLES
Ann Thorac Surg 2012;94:1718 –21
1720
CASE REPORT IHLBERG ET AL TAVI VIV IMPLANTATION FOR AORTIC ROOT HOMOGRAFT
FEATURE ARTICLES
The potential of the new TAVI technology is also being increasingly tested in patient groups outside of the current official indication areas. One such area consists of performing TAVI in patients with previous biological aortic valve prostheses (VinV). The limited experience so far is mainly in implantation to commercially available stented xenografts [5]. The VIV implantation within a failed homograft has been successfully reported in 2 articles to date [6, 7]. When planning the procedure, the primary implantation technique and the given size of the homograft should be acknowledged. However the choice of the proper transcatheter valve size is, in our opinion, based mainly on thorough analysis of both the transesophageal echocardiographic and MDCT angiographic imaging studies. Periprocedural contrast aortography is of limited use for valve positioning because the calcific landmarks of the valve annulus may not be clear, especially when severe aortic regurgitation is present (Fig 2). The degenerative failure mode of the valve cusps is mainly secondary to thinning, perforation, and tearing [3]. In contrast, the calcified cylinder of the homograft root can provide a very suitable platform for VinV implantation. Furthermore, the less bulky calcifications in the valve cusps might decrease the risk of coronary obstruction. However the technical suitability of the failed homograft root for TAVI needs to be assessed carefully on a case-by-case basis (Fig 3). In addition to the more widely used transfemoral, transapical, and subclavian TAVI access options, the transaortic approach has recently become a reasonable alternative. While retaining the advantageous features of a short implantation distance—such as good device maneuvering, positioning, and deployment control— the
Ann Thorac Surg 2012;94:1718 –21
Fig 3. The postoperative multidetector computed tomography (MDCT) angiogram demonstrates an optimal valve position in the aortic annulus. The left coronary ostium is not compromised.
potential benefits over the transapical route are multiple. There is better control of bleeding at the access site and left ventricular function is not impaired. There is also less associated pain, improved coughing, and respiratory dynamic status. Furthermore, off-pump concomitant coronary artery bypass grafting (ie, left internal mammary artery to left anterior descending artery bypass) can come into question in rare instances, and in the case of intraprocedural major complications, the upper partial sternotomy can be easily extended to a full sternotomy, allowing prompt conversion to rescue open heart operations. It is unproved whether these potential benefits of the Tao-TAVI approach could be translated into a better clinical outcome because controlled data are lacking. The only published retrospective series to date is of 17 patients with 30-day mortality of 11.8% [1]. In conclusion, this case demonstrates the feasibility of VinV transaortic TAVI to successfully treat a challenging case in a patient with a failed aortic root homograft. In our opinion there is clear potential to use this hybrid technique as a first-line option for patients with high or prohibitive operative risks.
References
Fig 2. In the intraoperative angiogram before the valve deployment, the calcific landmarks on the valve are poorly visualized. The clamp on the top of the distal ascending aorta demonstrates the planned access point.
1. Bapat V, Khawaja M, Attia L, et al. Transaortic transcatheter aortic valve implantation using Edwards SAPIEN valve: a novel approach. Catheter Cardiovasc Interv 2012;79:733– 40. 2. Gula G, Ahmed M, Thompson R, Radley-Smith R, Yacoub M. Combined homograft replacement of the aortic valve and root with reimplantation of coronary arteries. (abstract). Circulation 1976; 53(Suppl 2):150. 3. Sundt T, Rasmi N, Wong K, et al. Reoperative aortic valve operation after homograft root replacement: surgical options and results. Ann Thorac Surg 1995;60:S95–100.
Ann Thorac Surg 2012;94:1721–2
CASE REPORT KURISU ET AL AORTIC SURGERY AFTER THORACOPLASTY
1721
4. Joudinaud TM, Baron F, Raffoul R, et al. Redo aortic root surgery for failure of an aortic homograft is a major technical challenge. Eur J Cardiothorac Surg 2008;33:989 –94. 5. Webb J, Wood DA, Ye, J, et al. Transcatheter valve-in-valve implantation for failed bioprosthetic heart valves. Circulation 2010;121:1848 –57. 6. Dainese l, Fusari M, Trabattoni P, Biglioli P. Redo in aortic homograft replacement: transcatheter aortic valve as a valid alternative to surgical replacement. J Thorac Cardiovasc Surg 2010;139:1656 –7. 7. Schmoeckel M, Boekstegers P, Nikolau K, Reichardt B. First successful transapical aortic valve implantation after aortic allograft replacement. J Thorac Cardiovasc Surg 2009;138:1016 –7.
Repair of Acute Aortic Dissection in an Octogenarian With Prior Thoracoplasty Kazuhiro Kurisu, MD, Toshiro Iwai, MD, Yuichiro Kado, MD, Tomoyuki Ono, MD, Yuma Motomatsu, MD, and Yoshie Ochiai, MD
Cardiovascular surgery is challenging in patients who have previously undergone thoracoplasty because of severe chest deformity and impaired pulmonary function. We report a case of an octogenarian with prior left thoracoplasty, who successfully underwent surgical repair of an acute aortic dissection through a standard median sternotomy. We suggest that prior thoracoplasty might not necessarily be an exclusion criterion for aortic surgery in cases with adequate pulmonary function. (Ann Thorac Surg 2012;94:1721–2) © 2012 by The Society of Thoracic Surgeons
C
ardiac and aortic surgery are challenging in patients who have previously undergone thoracoplasty because of severe chest deformity and impaired pulmonary function, and have rarely been reported [1– 4]. The surgical approach to accessing the heart and great vessels and the severity of impaired pulmonary function are of great concern [1–3]. We report an octogenarian patient with prior thoracoplasty and current hemodialysis treatment who underwent surgical repair of an acute aortic dissection. A standard median sternotomy provided excellent exposure of the surgical field. Respiratory function did not deteriorate because sufficient control of fluid balance was achieved by intermittent hemodialysis.
Fig 1. Chest radiography showing left thoracoplasty.
empyema in 1965. She had a history of chronic liver dysfunction owing to hepatitis C infection and had abnormal levels of aspartate aminotransferase, alanine aminotransferase, and ammonia. Chest radiography showed a deformed left thorax and cardiomegaly, with a cardiothoracic ratio of 60% (Fig 1). Computed tomography scanning showed a localized dissection of the ascending aorta with a maximum diameter of 51 mm (Fig 2). A sanguineousappearing pericardial effusion was also identified. Despite the significant risks, especially in terms of pulmonary function, emergency surgery was planned for repair of her acute aortic dissection and cardiac tamponade. Respiratory function tests were not performed in this emergency situation. Surgery was performed through a conventional median sternotomy, which provided excellent exposure of
An 82-year-old woman, who had been treated with hemodialysis for over 20 years, suddenly experienced repeated chest discomfort and nausea and was given a diagnosis of acute aortic dissection. She had undergone left thoracoplasty for tuberculosis in 1948 and chest drainage for right Accepted for publication March 26, 2012. Address correspondence to Dr Kurisu, Department of Cardiovascular Surgery, Kyushu Kosei Nenkin Hospital, 1-8-1 Kishinoura, Yahatanishiku, Kitakyushu 806-8501, Japan; e-mail: [email protected].
© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
Fig 2. Computed tomography scan showing an intimal flap and acute dissection of the ascending aorta. Note the severe collapse of the left lung resulting from thoracoplasty. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2012.03.103
FEATURE ARTICLES
Department of Cardiovascular Surgery, Kyushu Kosei Nenkin Hospital, Kitakyushu, Japan
CASE REPORT IHLBERG ET AL TAVI VIV IMPLANTATION FOR AORTIC ROOT HOMOGRAFT
FEATURE ARTICLES
wound to the chest can have a wide range of clinical presentations, from no intrathoracic injury to extensive life-threatening great vessel damage, as outlined in this case. Injury to the pulmonary artery alone can be complex, albeit amenable to successful surgical repair [2]. In this case, there was additional injury to the inferomedial aspect of the aortic arch, which in itself could be fatal [3]. TTE to exclude a pericardial effusion can be a useful tool; however, it was a false-negative finding in this case. Negative findings, although initially reassuring, must not be misleading particularly in a case with penetrating trauma to the thoracic box. CT scans can aid operative planning and provide information on the location of the injury [4]. In this case, the CT scans provided an accurate location of the aortic arch injury, but were only suggestive of a pulmonary artery injury. This patient had no features of hemoptysis, which could be an indication of PA injury [2]. There have been reports of delayed cardiac tamponade following initial negative investigations [5]; therefore, a high index of suspicion for injury must be maintained in any patient with a penetrating injury to the thorax. The potential for a posterior right PA injury was recognized perioperatively by extending the anterior right PA injury. This could only be repaired by extension of the anterior tear. Transection of the aorta provided necessary access, to visualize and repair both the anterior and posterior walls of the right PA. The use of CPB facilitated this repair, and transection of the aorta should be considered when faced with extensive injuries to the pulmonary artery. This case illustrates the rapid decline in hemodynamic stability, resulting in cardiac arrest, associated with such an injury. This patient’s reasonable clinical status following initial resuscitation was falsely reassuring. In retrospect, the nature of the injury, initial hypotensive presentation, metabolic acidosis, chest radiographic findings, and initial CT thorax scan provided sufficient cause for earlier surgical exploration. Median sternotomy allowed establishment of CPB, HCA, and cardioplegic arrest and provided the best access for repair of the aortic arch and right PA. If this patient had remained cardiovascularly unstable and then arrested, a more utilized approach, of an urgent emergency room anterior bilateral thoracotomy may have been indicated [6]. This approach, although useful in most circumstances of penetrating thoracic injury, would not have allowed control of the bleeding, institution of central CPB, and surgical repair, because of the nature of these injuries. Correct interpretation of the CT scan facilitated the correct operative strategy and environment for this patient. A single stab injury to the thorax can cause extensive intrathoracic damage to the great vessels and is associated with morbid consequences. A high index of suspicion for intrathoracic injury should remain despite initial cardiovascular stability and early negative investigative findings. This suspicion should prompt further investigations and early surgical exploration as required. © 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2012;94:1718 –21
References 1. Fulton JO, de Groot KM, Buckels NJ, von Oppell UO. Penetrating injuries involving the intrathoracic great vessels. S Afr J Surg 1997;35:82– 6. 2. Deneuville M. Injury of the pulmonary artery and its branches due to penetrating chest trauma. Ann Vasc Surg 2000;14:463–7. 3. Buchan K, Robbs JV. Surgical management of penetrating mediastinal arterial trauma. Eur J Cardiothorac Surg 1995;9: 90 – 4. 4. Pereira SJ, Narrod JA. Repair of right pulmonary artery transection after blunt trauma. Ann Thorac Surg 2009;87: 939 – 40. 5. Mechem CC, Alam GA. Delayed cardiac tamponade in a patient with penetrating chest trauma. J Emerg Med 1997;15: 31–3. 6. Hunt PA, Greaves I, Owens WA. Emergency thoracotomy in thoracic trauma-a review. Injury 2006;37:1–19.
Transaortic Valve-in-Valve Implantation After Previous Aortic Root Homograft Leo Ihlberg, MD, PhD, Antero Sahlman, MD, Juha Sinisalo, MD, Janne Rapola, MD, PhD, and Mika Laine, MD, PhD Departments of Cardiothoracic Surgery and Cardiology, Helsinki University Hospital, Helsinki, Finland
Catheter-based valve implantation techniques are becoming a viable option in various clinical situations to replace difficult redo open heart surgical procedures. This is a report of a first, to our knowledge, successful valve-in-valve (VinV) transcatheter aortic valve implantation (TAVI) into a homograft through the transaortic (TAo) access route using an Edwards SAPIEN valve prosthesis (Edwards Lifesciences, LLC, Irvine, CA) in a patient with poor left ventricular function and generalized severe atherosclerosis. (Ann Thorac Surg 2012;94:1718 –21) © 2012 by The Society of Thoracic Surgeons
R
epeated aortic root operations for a failed homograft can be a technically challenging undertaking, especially if the whole aortic root needs to be replaced. Associated risks could even make a conventional open surgical approach prohibitive. Transcatheter aortic valve implantation (TAVI) is a new treatment modality that could potentially be used for this patient group. Herein we report the first, to our knowledge, valve-in-valve (VinV) TAVI into a homograft through the transaortic
Accepted for publication March 29, 2012. Address correspondence to Dr Ihlberg, Department of Cardiothoracic Surgery, Helsinki University Hospital, PO Box 340, FI-00029 Helsinki, Finland; e-mail: [email protected].
Dr Ihlberg discloses that he has a financial relationship with Edwards Lifesciences.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2012.03.111
Fig 1. Preoperative 3-dimensional multidetector computed tomography (MDCT) angiographic reconstruction depicts a complete circumferential calcification of the aortic root homograft. The distal ascending aorta is relatively free of disease.
(TAo) access route using an Edwards SAPIEN valve prosthesis (Edwards Lifesciences, Irvine, CA) in a patient with poor left ventricular function and generalized atherosclerosis. In 2001, a now 65-year-old man underwent an aortic root reconstruction with a homograft for native valve endocarditis. The anterior mitral leaflet of the homograft was used as a patch for a new fibrous body between the aortic and mitral valves. After adequate antimicrobial treatment, the patient recovered without any signs of reinfection. His other medical comorbidities included an asymptomatic chronic hepatitis C infection and severe lower extremity arteriopathy. Since 2009, a gradual worsening in his exercise tolerance had been noted and in June 2011 he presented in New York Heart Association class IV congestive heart failure and pulmonary edema. Moderate aortic stenosis was demonstrated by the transthoracic cardiac echocardiogram with peak and mean transvalvular gradients of 29 mm Hg and 15 mmHg, respectively. The valve opening area was 0.7 cm2. The aortic regurgitation was graded as severe. Left ventricular function was impaired with an ejection fraction of 20% and end-diastolic diameter of 65 mm. Severe pulmonary hypertension of 60 mm Hg was present. Coronary angiography revealed stenosis of 90% in his hypoplastic right coronary artery. Multidetector computed tomography (MDCT) angiography showed the aortic root homograft to be heavily calcified (Fig 1) on the valve leaflets and also circumferentially the entire length of the wall. The distal ascending aorta was relatively free of disease. A chronic total occlusion of the right iliac-femoral vessel and a severe calcification and narrowing of the lumen on the left side was also noted.
CASE REPORT IHLBERG ET AL TAVI VIV IMPLANTATION FOR AORTIC ROOT HOMOGRAFT
1719
His logistic EuroSCORE for conventional surgical treatment was 43.5%. The patient’s case was discussed in a multidisciplinary meeting and a joint decision to proceed with TAVI was made. The procedure was performed using general anesthesia with both fluoroscopic and transesophageal echocardiographic guidance using a 29-mm Edwards SAPIEN Transcatheter Heart Valve (Edwards Lifesciences). The TAo-TAVI was performed as previously described [1]. In brief, a temporary right ventricular pacemaker was placed through the right jugular vein. The left common femoral artery was cannulated with a 6F multipurpose MPA catheter (Boston Scientific Corp, Natick, MA). Access to the distal ascending aorta was gained through an upper partial J-shaped resternotomy to the right second intercostal space. Two pledgeted purse-string sutures were placed at the selected spot, which was chosen both by identifying a calcific-free spot in the preoperative MDCT angiogram and directly palpating the aorta. A direct needle puncture was performed to introduce a soft wire and a 6F multipurpose MPA catheter (Boston Scientific Corp). After the aortic valve was crossed with the wire, a preshaped Super Stiff Amplatz guidewire (Boston Scientific Corp) was placed into the left ventricle followed by insertion of an Ascendra sheath (Edwards Lifesciences) into the ascending aorta. First, a balloon valvuloplasty was performed with a 20 ⫻ 30 mm balloon followed by a successful implantation of a 29-mm Edwards SAPIEN valve (Edwards Lifesciences) into the desired position. These procedures were both performed during short bursts of rapid ventricular pacing at 180 beats/min. Optimal valve position and function could be demonstrated by both transesophageal echocardiography and aortic root angiography. He made an uneventful postoperative recovery and was discharged home 5 days after the procedure. At 6 months after the Tao-TAVI, he presented with significant clinical improvement and is in New York Heart Association class II. By transesophageal echocardiography, the left ventricular function is seen to have improved significantly and is now 40%. The respective mean and peak transvalvular gradients are 5 and 9 mm Hg, respectively, with no aortic regurgitation.
Comment Homograft aortic valve replacement using the freestanding root technique with reimplantation of the coronary arteries was introduced some 30 years ago [2]. Homografts however are of limited durability because of late degenerative valve failure and dense calcification, as with all other bioprosthetic aortic valve substitutes. Reoperation of the aortic valve can be performed in a subset of patients with insertion of a new valve within the previous root, but in cases of more extensive calcification, the only option is to take down the calcified homograft root and replace it again completely [3]. This is technically demanding and has led to significant perioperative mortality and morbidity, even in patients deemed fit for surgical intervention [3, 4].
FEATURE ARTICLES
Ann Thorac Surg 2012;94:1718 –21
1720
CASE REPORT IHLBERG ET AL TAVI VIV IMPLANTATION FOR AORTIC ROOT HOMOGRAFT
FEATURE ARTICLES
The potential of the new TAVI technology is also being increasingly tested in patient groups outside of the current official indication areas. One such area consists of performing TAVI in patients with previous biological aortic valve prostheses (VinV). The limited experience so far is mainly in implantation to commercially available stented xenografts [5]. The VIV implantation within a failed homograft has been successfully reported in 2 articles to date [6, 7]. When planning the procedure, the primary implantation technique and the given size of the homograft should be acknowledged. However the choice of the proper transcatheter valve size is, in our opinion, based mainly on thorough analysis of both the transesophageal echocardiographic and MDCT angiographic imaging studies. Periprocedural contrast aortography is of limited use for valve positioning because the calcific landmarks of the valve annulus may not be clear, especially when severe aortic regurgitation is present (Fig 2). The degenerative failure mode of the valve cusps is mainly secondary to thinning, perforation, and tearing [3]. In contrast, the calcified cylinder of the homograft root can provide a very suitable platform for VinV implantation. Furthermore, the less bulky calcifications in the valve cusps might decrease the risk of coronary obstruction. However the technical suitability of the failed homograft root for TAVI needs to be assessed carefully on a case-by-case basis (Fig 3). In addition to the more widely used transfemoral, transapical, and subclavian TAVI access options, the transaortic approach has recently become a reasonable alternative. While retaining the advantageous features of a short implantation distance—such as good device maneuvering, positioning, and deployment control— the
Ann Thorac Surg 2012;94:1718 –21
Fig 3. The postoperative multidetector computed tomography (MDCT) angiogram demonstrates an optimal valve position in the aortic annulus. The left coronary ostium is not compromised.
potential benefits over the transapical route are multiple. There is better control of bleeding at the access site and left ventricular function is not impaired. There is also less associated pain, improved coughing, and respiratory dynamic status. Furthermore, off-pump concomitant coronary artery bypass grafting (ie, left internal mammary artery to left anterior descending artery bypass) can come into question in rare instances, and in the case of intraprocedural major complications, the upper partial sternotomy can be easily extended to a full sternotomy, allowing prompt conversion to rescue open heart operations. It is unproved whether these potential benefits of the Tao-TAVI approach could be translated into a better clinical outcome because controlled data are lacking. The only published retrospective series to date is of 17 patients with 30-day mortality of 11.8% [1]. In conclusion, this case demonstrates the feasibility of VinV transaortic TAVI to successfully treat a challenging case in a patient with a failed aortic root homograft. In our opinion there is clear potential to use this hybrid technique as a first-line option for patients with high or prohibitive operative risks.
References
Fig 2. In the intraoperative angiogram before the valve deployment, the calcific landmarks on the valve are poorly visualized. The clamp on the top of the distal ascending aorta demonstrates the planned access point.
1. Bapat V, Khawaja M, Attia L, et al. Transaortic transcatheter aortic valve implantation using Edwards SAPIEN valve: a novel approach. Catheter Cardiovasc Interv 2012;79:733– 40. 2. Gula G, Ahmed M, Thompson R, Radley-Smith R, Yacoub M. Combined homograft replacement of the aortic valve and root with reimplantation of coronary arteries. (abstract). Circulation 1976; 53(Suppl 2):150. 3. Sundt T, Rasmi N, Wong K, et al. Reoperative aortic valve operation after homograft root replacement: surgical options and results. Ann Thorac Surg 1995;60:S95–100.
Ann Thorac Surg 2012;94:1721–2
CASE REPORT KURISU ET AL AORTIC SURGERY AFTER THORACOPLASTY
1721
4. Joudinaud TM, Baron F, Raffoul R, et al. Redo aortic root surgery for failure of an aortic homograft is a major technical challenge. Eur J Cardiothorac Surg 2008;33:989 –94. 5. Webb J, Wood DA, Ye, J, et al. Transcatheter valve-in-valve implantation for failed bioprosthetic heart valves. Circulation 2010;121:1848 –57. 6. Dainese l, Fusari M, Trabattoni P, Biglioli P. Redo in aortic homograft replacement: transcatheter aortic valve as a valid alternative to surgical replacement. J Thorac Cardiovasc Surg 2010;139:1656 –7. 7. Schmoeckel M, Boekstegers P, Nikolau K, Reichardt B. First successful transapical aortic valve implantation after aortic allograft replacement. J Thorac Cardiovasc Surg 2009;138:1016 –7.
Repair of Acute Aortic Dissection in an Octogenarian With Prior Thoracoplasty Kazuhiro Kurisu, MD, Toshiro Iwai, MD, Yuichiro Kado, MD, Tomoyuki Ono, MD, Yuma Motomatsu, MD, and Yoshie Ochiai, MD
Cardiovascular surgery is challenging in patients who have previously undergone thoracoplasty because of severe chest deformity and impaired pulmonary function. We report a case of an octogenarian with prior left thoracoplasty, who successfully underwent surgical repair of an acute aortic dissection through a standard median sternotomy. We suggest that prior thoracoplasty might not necessarily be an exclusion criterion for aortic surgery in cases with adequate pulmonary function. (Ann Thorac Surg 2012;94:1721–2) © 2012 by The Society of Thoracic Surgeons
C
ardiac and aortic surgery are challenging in patients who have previously undergone thoracoplasty because of severe chest deformity and impaired pulmonary function, and have rarely been reported [1– 4]. The surgical approach to accessing the heart and great vessels and the severity of impaired pulmonary function are of great concern [1–3]. We report an octogenarian patient with prior thoracoplasty and current hemodialysis treatment who underwent surgical repair of an acute aortic dissection. A standard median sternotomy provided excellent exposure of the surgical field. Respiratory function did not deteriorate because sufficient control of fluid balance was achieved by intermittent hemodialysis.
Fig 1. Chest radiography showing left thoracoplasty.
empyema in 1965. She had a history of chronic liver dysfunction owing to hepatitis C infection and had abnormal levels of aspartate aminotransferase, alanine aminotransferase, and ammonia. Chest radiography showed a deformed left thorax and cardiomegaly, with a cardiothoracic ratio of 60% (Fig 1). Computed tomography scanning showed a localized dissection of the ascending aorta with a maximum diameter of 51 mm (Fig 2). A sanguineousappearing pericardial effusion was also identified. Despite the significant risks, especially in terms of pulmonary function, emergency surgery was planned for repair of her acute aortic dissection and cardiac tamponade. Respiratory function tests were not performed in this emergency situation. Surgery was performed through a conventional median sternotomy, which provided excellent exposure of
An 82-year-old woman, who had been treated with hemodialysis for over 20 years, suddenly experienced repeated chest discomfort and nausea and was given a diagnosis of acute aortic dissection. She had undergone left thoracoplasty for tuberculosis in 1948 and chest drainage for right Accepted for publication March 26, 2012. Address correspondence to Dr Kurisu, Department of Cardiovascular Surgery, Kyushu Kosei Nenkin Hospital, 1-8-1 Kishinoura, Yahatanishiku, Kitakyushu 806-8501, Japan; e-mail: [email protected].
© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
Fig 2. Computed tomography scan showing an intimal flap and acute dissection of the ascending aorta. Note the severe collapse of the left lung resulting from thoracoplasty. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2012.03.103
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Department of Cardiovascular Surgery, Kyushu Kosei Nenkin Hospital, Kitakyushu, Japan