Interact CardioVasc Thorac Surg 2009;9:837-839. doi:10.1510/icvts.2009.211144
© 2009 European Association of Cardio-Thoracic Surgery
Proposal for bail-out procedures - Valves |
When operable patients become inoperable: conversion of a surgical aortic valve replacement into transcatheter aortic valve implantation
Lene Kjær Olsena,*,
Henrik Arendrupb,
Thomas Engstrøma and
Lars Søndergaarda
a Department of Cardiology, B 2014, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
b Department of Thoracic Surgery, Rigshospitalet, Copenhagen, Denmark
Received 18 May 2009;
received in revised form 12 August 2009;
accepted 12 August 2009
*Corresponding author. Tel.: +45 3545 2018; fax: +45 3545 2705.
E-mail address: lenekjaerolsen{at}gmail.com (L.K. Olsen).
 |
Abstract
|
|---|
Transcatheter aortic valve implantation (TAVI) is a relatively new treatment option for inoperable patients with severe aortic stenosis (AS). This case describes how a planned conventional surgical aortic valve replacement (AVR) on a 73-year-old woman was successfully converted to a TAVI procedure. On extracorporal circulation it was reconized that the aortic annulus, the coronary ostiae and the proximal part of the ascending aorta were severely calcified making valve implantation impossible. Surgical closure without valve substitution was estimated to be associated with a high risk of mortality due to the imparied left ventricular function. Consequently, TAVI was performed with a CoreValve ReValving® System prosthesis. The delivery of the valve prosthesis was made through the ascending part of aorta, proximal of the cannulation of aorta. Positioning of the valve prosthesis was made under visual guidance, and the prosthesis was sutured to the ascending aorta. With some manipulation of the prosthesis it was possible to suture the aorta circumferentially around the fully expanded upper part of the prosthesis. Post-procedurally the patient recovered successfully, with improved function capacity, aortic valve area and left ventricle function.
Key Words: Aortic stenosis; Inoperable; Transcatheter aortic valve implantation; Aortic valve replacement
|
1. Introduction
|
|---|
Transcatheter aortic valve implantation (TAVI) has been introduced as a treatment modality applied on inoperable patients with severe symptomatic aortic stenosis (AS), and has demonstrated itself to be an efficient and safe treatment option [1]. A case of bail-out of TAVI due to complications with conversion to conventional surgical aortic valve replacement (AVR) has been reported [2]. This article presents a case where a patient, during elective cardiac surgery, turned out to be inoperable due to severe calcification of the aortic annulus, around the coronary ostiae and the proximal part of the ascending aorta. Due to impaired ejection fraction of the left ventricle the postoperative risk of mortality was considered unacceptable without valve substitution. However, the procedure was successfully converted into transcatheter-based valve implantation, using the self-expanding CoreValve ReValving® Systems prosthesis, in a non-hybrid operating theater. To our knowledge, this is the first-in-man reported case of conversion of a conventional surgical AVR to a TAVI procedure.
|
2. Medical and surgical history
|
|---|
A 73-year-old woman with severe AS and a medical history of atrial fibrillation, arterial hypertension, pulmonary hypertension and hypercholesterolemia. The logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) was 15%. Over the last couple of years, the patient had developed progressive exercise incapacity and was in New York Heart Association (NYHA) functional class IV, but without angina. Transthoracic echocardiography showed severe AS with an aortic valve area of 0.6 cm2, aortic annulus diameter of 23 mm and a left ventricle ejection fraction of 30%. Coronary angiography demonstrated no significant stenoses. The patient was considered operable and a candidate for conventional surgical AVR on a multidisciplinary conference on the basis of current guidelines [3].
|
3. Procedure
|
|---|
An elective surgical AVR was initiated under general anesthesia, sternotomy, cannulation of aorta, extracorporal circulation and cardioplegia. The proximal part of the ascending aorta was opened, and the aortic ostia revealed a tricuspid aortic valve. However, due to heavy calcification of the aortic annulus around the coronary ostiae and the proximal part of the ascending aorta, a traditional AVR procedure was considered impossible. Therefore, interventional cardiologists with expertise in TAVI were consulted, and it was agreed to proceed with a conversion of the procedure to TAVI. The course of the procedure demonstrated two critical steps. Firstly, the positioning of the CoreValve prosthesis, and secondly, the closing of the aorta circumferentially around the valve prosthesis.
The CoreValve prosthesis was prepared in cold water and loaded in the delivery system as is usual in TAVI procedures. In order to accommodate the valve prosthesis, a balloon dilatation of the aortic annulus with a 22-mm NucleusTM balloon was made. The ventricle near part of the delivery system was placed within the aortic annulus through the open part of the ascending aorta, and the valve was released under the guidance of direct vision. Due to the properties of the nitinol composition of the CoreValve prosthesis the body temperature caused the frame to transform into the expected ‘memory shape'. This is illustrated by Fig. 1, where a fully expanded prosthesis is seen within the aortic annulus. With the purpose of maintaining the position of the prosthesis under manipulation of aorta it was fixated by suturing the prosthesis frame to the proximal part of the ascending aorta.
View larger version (123K):
[in this window]
[in a new window]
|
Fig. 1. The CoreValve® prosthesis situated within the aortic annulus. Notice the fully expanded aortic near part of the prosthesis frame and how each of the prosthesis valve leaflets are seen.
|
|
In order to close the ascending aorta around the fully expanded prosthesis, it was necessary to continuously pour cold water over the prosthesis. By lowering the temperature of the nitinol the radial force of the CoreValve frame was reduced. Furthermore, a suture was passed between the struts in the aortic near part of the frame, and the two ends of the suture were then pulled together, whereby the frame diameter was reduced. Subsequently, it was possible to close the incision in the aorta, removing the suture from the frame before the last stitch. The process of diminishing the diameter of the upper part of the prosthesis and closing the aorta can be seen in, respectively, Videos 1 and 2.
The patient was extubated three days after the procedure, stayed a total of four days in intensive care unit and was discharged 11 days after the procedure. At discharge, the patient had a maximal transvavular gradient of 14 mmHg and an ejection fraction of 40–45% evaluated by transthoracic echocardiography. Post-interventionally an ECG-gated computer tomography visualized the correct position of the valve prosthesis. This is illustrated in Fig. 2.
View larger version (118K):
[in this window]
[in a new window]
|
Fig. 2. Post-interventional ECG-gated computer tomography of the heart shows the CoreValve® prosthesis situated within the aortic position. The ventricular near part of the prosthesis frame is estimated to be 5–7 µm below the aortic annulus.
|
|
|
4. Discussion
|
|---|
TAVI is a rapidly emerging treatment modality in inoperable patients with AS. Even though the technique has been reported to be efficient and safe it carries a risk, and examples of emergency conversion of TAVI into AVR are described [2]. Also, elective hybrid procedure using the ascending aorta as vascular access for TAVI with a CoreValve prosthesis has been reported [4]. Therefore, excessive evaluation and anticipation of technical difficulties is needed in deciding referral to either AVR or TAVI.
This case reports the first emergency conversion of AVR to TAVI in a patient with severe calcification of the aortic root. This approach causes several issues not seen when using the femoral access. Firstly, the positioning of the valve was made under direct vision as well as manual palpation in evaluating the ventricular position. Secondly, it was estimated during manipulation and positioning of the valve prosthesis that fixation of the valve, besides the radial force of the frame, was needed. This was managed by several sutures anchoring the prosthesis to the ascending aorta. Thirdly, it was necessary to diminish the aortic near part of the frame in order to close the aorta. Due to the shorter profile of an Edwards Sapien valve closing of the aorta had probably not been an issue. Possible disadvantages of the use of a CoreValve prosthesis is the lack of knowledge of durability of the valve. However, in this case it was predicted to be the best option for a good prognosis for the patient. An advantage of a TAVI prosthesis in general compared to a surgically implanted prosthesis is the lower post-interventional gradient across the valve.
|
References
|
|---|
- Piazza N, Grube E, Gerckens U, den Heijer P, Linke A, Luha O, Ramondo A, Ussia G, Wenaweser P, Windecker S, Laborde JC, de Jaegere P, Serruys PW. Procedural and 30-day outcomes following transcatheter aortic valve implantation using the third generation (18 Fr) CoreValve revalving system: results from the multicentre, expanded evaluation registry 1-year following CE mark approval. EuroIntervention 2008;4:242–249.[Medline]
- Litzler PY, Cribier A, Zajarias A, Comte D, Eltchaninoff H, Tron C, Haas-Hubscher C, Bessou JP. Surgical aortic valve replacement after percutaneous aortic valve implantation: what have we learned. J Thorac Cardiovasc Surg 2008;136:697–701.[Abstract/Free Full Text]
- Bauernschmitt R, Schreiber C, Bleiziffer S, Ruge H, Mazzitelli D, Hutter A, Tassani P, Lange R. Transcatheter aortic valve implantation through the ascending aorta: an alternative option for no-access patients. Heart Surg Forum 2009;12:E63–E64.[CrossRef][Medline]
- Bonow RO, Carabello BA, Kanu C, de Leon AC Jr, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Antman EM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. Circulation 2006;114:84–231.[CrossRef]
Related Article
-
eComment. Sutureless aortic valve implantation in cases of calcified aortic annuli
- Nawid Khaladj, Christian Hagl, Axel Haverich, and Malakh Shrestha
Interactive CardioVascular and Thoracic Surgery 2009 9: 839.
[Full Text]
[PDF]
This article has been cited by other articles:
|
|
|
|
 
N. Khaladj, C. Hagl, A. Haverich, and M. Shrestha
eComment. Sutureless aortic valve implantation in cases of calcified aortic annuli
Interactive CardioVascular and Thoracic Surgery,
November 1, 2009;
9(5):
839 - 839.
[Full Text]
[PDF]
|
|
|
|
|
Top
Abstract
1. Introduction
