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Transapical Cannulation Through a Transcatheter Aortic Valve Implantation Valve: A Novel Approach for Cardiogenic Collapse
CASE REPORT
Transapical Cannulation Through a Transcatheter Aortic Valve Implantation Valve: A Novel Approach for Cardiogenic Collapse Louis Philippe Tremblay, MD,* Claudia Cote, BSc,* and Marc P. Pelletier, MD† We report a case of rescue bypass cannulation of the ventricular apex during a transapical transcatheter aortic valve implantation procedure in a patient with peripheral vascular disease not amenable to peripheral cannulation. Following rapid pacing and deployment of the transcatheter valve, cardiac function did not recover. The arterial cannula was inserted through the left ventricular apex, at the site of the transapical sheath, and advanced across the prosthetic valve, allowing for rapid initiation of cardiopulmonary bypass. The patient's ventricular function recovered promptly and cardiopulmonary bypass was weaned without difficulty. Semin Thoracic Surg ]:]]]–]]] I 2016 Published by Elsevier Inc.
Fluoroscopic image of arterial cannula across newly implanted valve.
Keywords: aortic valve, replacement, cardiopulmonary bypass, CPB, heart valve replacement, transapical, percutaneous
Central Message
INTRODUCTION For patients in whom the risk of a standard aortic valve replacement is high, transcatheter aortic valve implantation (TAVI) has become the favored procedure 1 accounting for over 10% of aortic valve procedures in France and Italy and over 45% in Germany.2 Although most can be performed through peripheral access, peripheral vascular disease (PVD) may preclude this option. For these patients, the left ventricular apex, through a small thoracotomy, provides an alternative. In such cases, should rescue cardiopulmonary bypass (CPB) for cardiogenic collapse be required, cannulation of the femoral vessels is the standard approach. Cases of left ventricular apex cannulation for patients with severely calcified femoral vessels are much less described.3,4 CLINICAL SUMMARY A 79-year old was referred with angina and dyspnea of NYHA Class III severity. His history included a myocardial infarction in 1992, coronary artery bypass grafting (CABG), *Division of Cardiac Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada † Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, MA, USA
Dr Pelletier reports receiving fees from Edwards and St. Jude. Drs Tremblay and Cote have no commercial interests to disclose. Address reprint requests to Marc P. Pelletier, MD, Division of Cardiac Surgery, New Brunswick, Heart Center, Saint John Regional Hospital, P.O. Box 2100, Saint John, New Brunswick, Canada E2L 4L2. E-mail: [email protected]; [email protected]
1043-0679/$-see front matter ª 2016 Published by Elsevier Inc. http://dx.doi.org/10.1053/j.semtcvs.2016.05.012
We report successful transvalvular apical arterial cannulation for rescue cardiopulmonary bypass during TAVI in a patient with severe vascular disease.
multiple angiograms with stenting and redilatation of in-stent stenoses, aortic stenosis, and bilateral femoral stenting. Angiography revealed diffusely diseased coronary arteries and poor ventricular function. The patient's previous left internal thoracic artery to left anterior descending graft was patent but all other grafts were diseased. The coronary disease was not amenable to revascularization. Transesophageal echocardiography (TEE) revealed an aortic valve area of 0.72 cm2, a heavily calcified aortic valve, a mean gradient of 20 mm Hg, and ejection fraction of 20%. A computed tomography revealed an aortic valve annular diameter of 27.3 mm, a left main height of 14 mm, and severe bilateral PVD with eccentric calcification of the femoral vessels. It was felt the right femoral artery might be amenable to cannulation should CPB be required. Given the vasculopathy, previous CABG, and nongraftable coronary disease, he was offered a TAVI with salvage CPB through the right femoral approach in the event of hemodynamic collapse. The right femoral vessels were mobilized after induction with cannulation of the right femoral vein using an Estech RAP Femoral Venous Cannula 23/25 Fr (Sorin, Milan, Italy). The right femoral artery was found to be concentrically calcified and not amenable to cannulation. The decision was made to abandon this strategy, with a plan to utilize the left ventricular apex for arterial CPB outflow, should it be required. A 7 cm anterolateral thoracotomy incision was made in the fifth intercostal space, and the left ventricular apex was cannulated. Through a 24 Fr sheath, the aortic valve was dilated with a 25 mm balloon under rapid pacing, throughout which 1
TRANSAPICAL CANNULATION
Figure. Fluoroscopic image of arterial cannula across newly implanted valve. (A) Venous cannula (Sorin, Milan, ITA), (B) arterial cannula (Medtronic, Minneapolis, MN), (C) sapien valve (Edwards Lifesciences, Irvine, CA), (D) Swan-Ganz catheter, and (E) transesophageal echocardiogram probe.
the patient remained stable. A 29 mm Edwards SAPIEN-XT transcatheter heart valve (Edwards Lifesciences, Irvine, CA) was advanced, its position confirmed by angiography and TEE, and under rapid pacing the valve was deployed. When the balloon was deflated, the patient did not recover from rapid pacing, with no meaningful ventricular function. TEE confirmed lack of cardiac contractility. CPR was started, and a decision was made for urgent CPB. Given the extent of PVD, we chose to avoid cannulation of the left femoral artery. The ventricular apex sheath was replaced with a 24-Fr EOPA cannula (Medtronic Inc, Minneaoplis, MN), leaving the guide wire in position. The cannula was advanced through the 29 mm Sapien XT valve and into the ascending aorta under fluoroscopy (Fig. 1) to prevent ventricular distension. The patient was placed on CPB within a few minutes of valve deployment. Flows of 3.6-4 L/min were obtained on bypass and the ventricle recovered. The patient was weaned from CPB after 12 minutes and the cannula was removed under rapid pacing.
COMMENT For complex patients, CPB may support hemodynamic instability around the time of valve implantation. Performing a TAVI with back-up CPB support has been strongly recommended in patients with markedly reduced ventricular function5 and cannulation options may be limited because of the advanced vascular disease. Although this method has been recently described in the literature,3,4 we believe this is the first reported case with a favorable long-term outcome. It remains to be determined if the prosthetic anchoring system can withstand further cannulation attempts as it did in this case, but we believe that this rescue cannulation method is a viable alternative when standard access is not possible.
TEE confirmed proper valve positioning with trivial paravalvular insufficiency, and a mean gradient of 9 mm Hg. The patient was transferred to the intensive care unit and discharged home on day 4.
SUPPLEMENTARY INFORMATION Supplementary data associated with this article can be found in the online version at doi:10.1053/j. semtcvs.2016.05.012.
2
At 1 year following the TAVI, echocardiogram revealed an ejection fraction of 38%, aortic valve area of 1.6 cm2, mean gradient of 7 mm Hg, and no paravalvular leak. The patient reported ongoing functional class II angina with NYHA I symptoms.
Seminars in Thoracic and Cardiovascular Surgery Volume ], Number ]
TRANSAPICAL CANNULATION 1. Cribier A: Development of transcatheter aortic 3. Nakabayashi K, Koide M, Okada H, et al: Emercardiopulmonary bypass in transcatheter aortic valve implantation (TAVI): A 20-year odyssey. gent extracorporeal circulation for refractory valve replacement. Ann Thorac Surg 98: Arch Cardiovasc Dis 105(3):146-152, 2012 ventricular fibrillation via transapical cannula1482-1484, 2014 2. Mylotte D, Osnabrugge RL, Windecker S, et al: tion as an arterial line during transapical trans- 5. Unbehaun A, Pasic M, Buz S, et al: Transapical catheter aortic valve replacement. J Am Coll aortic valve implantation in patients with Transcatheter aortic valve replacement in Europe: Adoption trends and factors influencing Cardiol Interv 8(15):e269-e270, 2015 severely depressed left ventricular function. device utilization. J Am Coll Cardiol 62(3): 4. Brinster DR, Patel JA, McCarthy HL, et al: J Thorac Cardiovasc Surg 143(6):1356-1363, 210-219, 2013 Transapical arterial cannulation for salvage 2012
Seminars in Thoracic and Cardiovascular Surgery Volume ], Number ]
3
Transapical Cannulation Through a Transcatheter Aortic Valve Implantation Valve: A Novel Approach for Cardiogenic Collapse Louis Philippe Tremblay, MD,* Claudia Cote, BSc,* and Marc P. Pelletier, MD† We report a case of rescue bypass cannulation of the ventricular apex during a transapical transcatheter aortic valve implantation procedure in a patient with peripheral vascular disease not amenable to peripheral cannulation. Following rapid pacing and deployment of the transcatheter valve, cardiac function did not recover. The arterial cannula was inserted through the left ventricular apex, at the site of the transapical sheath, and advanced across the prosthetic valve, allowing for rapid initiation of cardiopulmonary bypass. The patient's ventricular function recovered promptly and cardiopulmonary bypass was weaned without difficulty. Semin Thoracic Surg ]:]]]–]]] I 2016 Published by Elsevier Inc.
Fluoroscopic image of arterial cannula across newly implanted valve.
Keywords: aortic valve, replacement, cardiopulmonary bypass, CPB, heart valve replacement, transapical, percutaneous
Central Message
INTRODUCTION For patients in whom the risk of a standard aortic valve replacement is high, transcatheter aortic valve implantation (TAVI) has become the favored procedure 1 accounting for over 10% of aortic valve procedures in France and Italy and over 45% in Germany.2 Although most can be performed through peripheral access, peripheral vascular disease (PVD) may preclude this option. For these patients, the left ventricular apex, through a small thoracotomy, provides an alternative. In such cases, should rescue cardiopulmonary bypass (CPB) for cardiogenic collapse be required, cannulation of the femoral vessels is the standard approach. Cases of left ventricular apex cannulation for patients with severely calcified femoral vessels are much less described.3,4 CLINICAL SUMMARY A 79-year old was referred with angina and dyspnea of NYHA Class III severity. His history included a myocardial infarction in 1992, coronary artery bypass grafting (CABG), *Division of Cardiac Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada † Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, MA, USA
Dr Pelletier reports receiving fees from Edwards and St. Jude. Drs Tremblay and Cote have no commercial interests to disclose. Address reprint requests to Marc P. Pelletier, MD, Division of Cardiac Surgery, New Brunswick, Heart Center, Saint John Regional Hospital, P.O. Box 2100, Saint John, New Brunswick, Canada E2L 4L2. E-mail: [email protected]; [email protected]
1043-0679/$-see front matter ª 2016 Published by Elsevier Inc. http://dx.doi.org/10.1053/j.semtcvs.2016.05.012
We report successful transvalvular apical arterial cannulation for rescue cardiopulmonary bypass during TAVI in a patient with severe vascular disease.
multiple angiograms with stenting and redilatation of in-stent stenoses, aortic stenosis, and bilateral femoral stenting. Angiography revealed diffusely diseased coronary arteries and poor ventricular function. The patient's previous left internal thoracic artery to left anterior descending graft was patent but all other grafts were diseased. The coronary disease was not amenable to revascularization. Transesophageal echocardiography (TEE) revealed an aortic valve area of 0.72 cm2, a heavily calcified aortic valve, a mean gradient of 20 mm Hg, and ejection fraction of 20%. A computed tomography revealed an aortic valve annular diameter of 27.3 mm, a left main height of 14 mm, and severe bilateral PVD with eccentric calcification of the femoral vessels. It was felt the right femoral artery might be amenable to cannulation should CPB be required. Given the vasculopathy, previous CABG, and nongraftable coronary disease, he was offered a TAVI with salvage CPB through the right femoral approach in the event of hemodynamic collapse. The right femoral vessels were mobilized after induction with cannulation of the right femoral vein using an Estech RAP Femoral Venous Cannula 23/25 Fr (Sorin, Milan, Italy). The right femoral artery was found to be concentrically calcified and not amenable to cannulation. The decision was made to abandon this strategy, with a plan to utilize the left ventricular apex for arterial CPB outflow, should it be required. A 7 cm anterolateral thoracotomy incision was made in the fifth intercostal space, and the left ventricular apex was cannulated. Through a 24 Fr sheath, the aortic valve was dilated with a 25 mm balloon under rapid pacing, throughout which 1
TRANSAPICAL CANNULATION
Figure. Fluoroscopic image of arterial cannula across newly implanted valve. (A) Venous cannula (Sorin, Milan, ITA), (B) arterial cannula (Medtronic, Minneapolis, MN), (C) sapien valve (Edwards Lifesciences, Irvine, CA), (D) Swan-Ganz catheter, and (E) transesophageal echocardiogram probe.
the patient remained stable. A 29 mm Edwards SAPIEN-XT transcatheter heart valve (Edwards Lifesciences, Irvine, CA) was advanced, its position confirmed by angiography and TEE, and under rapid pacing the valve was deployed. When the balloon was deflated, the patient did not recover from rapid pacing, with no meaningful ventricular function. TEE confirmed lack of cardiac contractility. CPR was started, and a decision was made for urgent CPB. Given the extent of PVD, we chose to avoid cannulation of the left femoral artery. The ventricular apex sheath was replaced with a 24-Fr EOPA cannula (Medtronic Inc, Minneaoplis, MN), leaving the guide wire in position. The cannula was advanced through the 29 mm Sapien XT valve and into the ascending aorta under fluoroscopy (Fig. 1) to prevent ventricular distension. The patient was placed on CPB within a few minutes of valve deployment. Flows of 3.6-4 L/min were obtained on bypass and the ventricle recovered. The patient was weaned from CPB after 12 minutes and the cannula was removed under rapid pacing.
COMMENT For complex patients, CPB may support hemodynamic instability around the time of valve implantation. Performing a TAVI with back-up CPB support has been strongly recommended in patients with markedly reduced ventricular function5 and cannulation options may be limited because of the advanced vascular disease. Although this method has been recently described in the literature,3,4 we believe this is the first reported case with a favorable long-term outcome. It remains to be determined if the prosthetic anchoring system can withstand further cannulation attempts as it did in this case, but we believe that this rescue cannulation method is a viable alternative when standard access is not possible.
TEE confirmed proper valve positioning with trivial paravalvular insufficiency, and a mean gradient of 9 mm Hg. The patient was transferred to the intensive care unit and discharged home on day 4.
SUPPLEMENTARY INFORMATION Supplementary data associated with this article can be found in the online version at doi:10.1053/j. semtcvs.2016.05.012.
2
At 1 year following the TAVI, echocardiogram revealed an ejection fraction of 38%, aortic valve area of 1.6 cm2, mean gradient of 7 mm Hg, and no paravalvular leak. The patient reported ongoing functional class II angina with NYHA I symptoms.
Seminars in Thoracic and Cardiovascular Surgery Volume ], Number ]
TRANSAPICAL CANNULATION 1. Cribier A: Development of transcatheter aortic 3. Nakabayashi K, Koide M, Okada H, et al: Emercardiopulmonary bypass in transcatheter aortic valve implantation (TAVI): A 20-year odyssey. gent extracorporeal circulation for refractory valve replacement. Ann Thorac Surg 98: Arch Cardiovasc Dis 105(3):146-152, 2012 ventricular fibrillation via transapical cannula1482-1484, 2014 2. Mylotte D, Osnabrugge RL, Windecker S, et al: tion as an arterial line during transapical trans- 5. Unbehaun A, Pasic M, Buz S, et al: Transapical catheter aortic valve replacement. J Am Coll aortic valve implantation in patients with Transcatheter aortic valve replacement in Europe: Adoption trends and factors influencing Cardiol Interv 8(15):e269-e270, 2015 severely depressed left ventricular function. device utilization. J Am Coll Cardiol 62(3): 4. Brinster DR, Patel JA, McCarthy HL, et al: J Thorac Cardiovasc Surg 143(6):1356-1363, 210-219, 2013 Transapical arterial cannulation for salvage 2012
Seminars in Thoracic and Cardiovascular Surgery Volume ], Number ]
3