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a Department of Cardiac Surgery, Universität Leipzig, Herzzentrum, Leipzig, Germany
b Department of Anaesthesia, Universität Leipzig, Herzzentrum, Leipzig, Germany
c Department of Cardiology, Universität Leipzig, Herzzentrum, Leipzig, Germany
d Edwards Laboratories, Irvine, California
Accepted for publication December 13, 2007.
* Address correspondence to Dr Walther, Universität Leipzig, Herzzentrum, Klinik für Herzchirurgie, Strümpellstr. 39, 04289, Leipzig, Germany (Email: walt{at}medizin.uni-leipzig.de).
| Dr Dehdashtian discloses that he has a financial relationship with Edwards Lifesciences.
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Abstract |
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Heart valve replacement is a routinely performed in elderly patients using third-generation xenografts, with modern anticalcification treatment providing good hemodynamic function and sufficient longevity [1]. However, xenograft degeneration with subsequent repeat stenosis or incompetence requiring reoperation may occur. Reoperation is technically feasible in most patients, but the risk may be increased. Relatively few studies are published on such patients, but most quote a mortality risk for valve reoperation between 6% and 15% [2, 3]. Transcatheter heart valve implantation has been recently introduced into clinical practice using transfemoral and transapical approaches [4–6]. On the basis of this experience together with experimental testing demonstrating excellent results for valve-in-a-valve (VinV) implantation [7] we were able to successfully perform VinV implantation.
In March 2007, an 82-year-old woman presented with symptomatic (New York Heart Association Functional Class III) aortic xenograft stenosis 9 years after receiving a 21-mm Perimount prosthesis (Edwards Lifesciences, Irvine, CA). Echocardiography revealed severe aortic stenosis with a maximum flow velocity of 4.5 m/s, a valve opening area of 0.8 cm2, and severely restricted cusp motion. Because of her significantly increased perioperative risk, with a logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) predicted risk for death of 21%, and the Society Thoracic Surgeons risk assessment of 9.2%, she was considered for transapical minimally invasive off-pump VinV implantation. The patient gave informed consent for a protocol that has been approved by our local Ethics Board. Valve size selection for VinV implantation was based on specific bench testing.
The VinV implantation was performed in a hybrid operative theatre. Femoral arterial and venous wires were inserted percutaneously, and an arterial sheath was placed. This would allow for immediate femoral cannulation and initiation of cardiopulmonary bypass, if required. A pigtail catheter was introduced through the arterial sheath into the aortic root for angiographic visualization. After an anterolateral minithoracotomy in the fifth intercostal space and vertical pericardiotomy, two purse-string sutures were placed in the apex of the left ventricle.
The Seldinger technique was used to insert a 14F sheath antegrade across the stenosed xenograft. A superstiff guidewire was then introduced across the aortic arch into the descending aorta. Balloon dilatation of the stenosed xenograft was performed during a brief episode of rapid ventricular pacing (RVP) at 150 beats/min.
A 33F transapical sheath and a cuffed Cribier Edwards transcatheter valve (Edwards Lifesciences) were subsequently inserted. The valve was positioned with the lower edge approximately 2 mm below the circular metal band of the stenosed xenograft (Fig 1). The VinV implantation was performed by inflating the balloon during a second episode of RVP (Fig 2). Good VinV position with full stent expansion and a slightly concave stent configuration at the inflow and outflow aspect was obtained (Fig 3). The guidewire and sheath were retrieved, and the left ventricular apex and the minithoracotomy were closed.
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Comment |
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TopAbstractIntroductionCommentReferences |
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The minimally invasive approach and the good hemodynamic outcome led to a fast and uneventful recovery in our patient. It is possible that such minimally invasive VinV re-replacement procedures may lead to more frequent use of xenografts during initial heart valve procedures or a lowering of the recommended age for bioprosthetic implantation in the future.
Future consideration of VinV procedures in patients with failing bioprosthetic valves should take into account the different failure modes of porcine vs pericardial xenografts. Whereas bovine pericardium tends to have progressive stiffening that leads to stenosis, porcine cusps tend to develop severe calcification that may potentially lead to a higher risk of embolization during VinV implantation. We believe that minimally invasive beating heart off-pump VinV implantation offers a valuable therapeutic option for future patients, especially for those at high surgical risk.
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