Ann Thorac Surg 2012;93:e89-e91. doi:10.1016/j.athoracsur.2011.11.019
© 2012 The Society of Thoracic Surgeons
Case Reports
TAVI for Pure Aortic Valve Insufficiency in a Patient With a Left Ventricular Assist Device
Giuseppe D'Ancona, MD, PhD,
Miralem Pasic, MD, PhD*,
Semih Buz, MD,
Thorsten Drews, MD,
Stephan Dreysse, MD,
Roland Hetzer, MD, PhD,
Axel Unbehaun, MD
Deutsches Herzzentrum Berlin, Berlin, Germany
Accepted for publication November 7, 2011.
* Address correspondence to Dr Pasic, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, D-13353 Berlin, Germany (Email: pasic{at}dhzb.de).
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Abstract
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We report transcatheter aortic valve implantation (TAVI) for pure aortic valve insufficiency in a patient with an otherwise normal aortic valve and a long-term left ventricular assist device (LVAD). An oversized 29-mm Edwards SAPIEN valve (Edwards Lifesciences, Irvine, CA) was implanted in the 21-mm native aortic valve annulus. Despite the complete absence of aortic calcifications, the prosthesis remained stably anchored inside the annulus. The reported experience demonstrates that TAVI is feasible even in patients with pure aortic valve regurgitation and can be a reasonable option in patients with aortic regurgitation after LVAD implantation.
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Introduction
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| Drs Pasic, Unbehaun, Drews, Buz, and Dreysse disclose that they have financial relationships with Edwards Lifesciences.
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Severe aortic valve regurgitation can result from left ventricular assist device (LVAD) implantation even in patients with anatomically normal aortic valves [1]. This condition often leads to recurrence of symptoms and represents a real medical challenge.
A 63-year-old male patient with an LVAD was readmitted to our institution with increasing shortness of breath at rest during the preceding month. His medical history included ischemic cardiomyopathy, severe peripheral vascular disease, and type II diabetes mellitus. He had undergone an LVAD implantation (HeartWare International Inc, Miami Lakes, FL) from the left ventricular apex to the descending thoracic aorta through a left thoracotomy in January 2010. Thereafter the patient remained asymptomatic with a good general status. On admission, the LVAD function was completely satisfactory. Echocardiography showed a new finding of aortic valve insufficiency of grade II-III (Fig 1). Except for an altered coapting function of the cusps, there were no other pathologic findings seen on the valve. The cusps and the annulus were completely free of any calcification or degeneration (Figs 1 and 2).
Despite optimization of medical treatment, including continuous intravenous dobutamine infusion, the symptoms did not diminish. Therefore he was scheduled for surgical treatment to resolve the pathologic functioning of the aortic valve.
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Fig 1. Echocardiogram shows aortic valve insufficiency jet (white arrow heads) and native aortic valve without calcification (white arrow).
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Fig 2. Cardiac computed tomographic scan demonstrating no calcification in the aortic valve (black asterisk).
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We decided to implant an oversized balloon-expandable transcatheter aortic valve prosthesis. Because of the extensive peripheral vascular disease, a transapical approach was used. Preoperative chest computed tomography clearly showed a possible route of implantation after evaluation of the relationship between the left ventricular apex, the LVAD, and the left-sided chest bony structures. Transapical transcatheter aortic valve implantation (TAVI) was performed by the senior author (MP) and our TAVI team. Direct access to the left ventricular apex without compromising the previously placed LVAD apical cannula seemed possible (Fig 3). The groin vessels were cannulated for femorofemoral cardiopulmonary bypass (CPB). A small left anterior thoracotomy was performed in the sixth intercostal space. The LVAD apical cannula was neither dissected free nor visualized. After initiation of CPB, the LVAD function was temporarily stopped to prevent inadvertent air suctioning and to allow filling of the left ventricle. A 29-mm Edwards SAPIEN valve (Edwards Lifesciences, Irvine, CA) was slowly deployed under angiographic and echocardiographic guidance (Fig 4) [2]. Once the LVAD function was restarted, the patient was easily weaned from CPB. In the following hours he was extubated and completely weaned from pharmacologic inotropic support; he was transferred to the regular ward on the first postoperative day. The symptoms receded immediately. Postoperative echocardiographic checks and chest radiography (Fig 5) confirmed adequate positioning of the valve and no transvalvular or paraprosthetic regurgitation.
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Fig 3. Preoperative computed tomographic scan showing the chosen direct surgical access (white arrow) to puncture the left ventricular apex in the anterior aspect, avoiding the ventricular assist device (black asterisk).
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Fig 4. Sequences of transcatheter aortic valve implantation. The valve (black arrow) is released slowly and during simultaneous contrast injection (white arrow). (A) Angiography immediately before starting balloon inflation; (B) initial balloon inflation for valve deployment; (C) almost complete balloon inflation with angiography to verify valve position; (D) complete balloon inflation and valve deployment.
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Fig 5. Postoperative chest roentgenogram showing stable valve position and anchoring (white arrow). Note the left ventricular assist device in the left ventricular apex (black asterisk) and the outflow cannula of the device in the thoracic descending aorta (black arrow).
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Comment
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Transcatheter aortic valve implantation in patients with previously implanted LVADs has never, to our knowledge, been reported before. Additionally, TAVI in patients with pure aortic insufficiency with otherwise normal native aortic valves has never, to the best of our knowledge, been documented in the literature. TAVI in patients with pure aortic valve regurgitation and without valve calcification or degeneration is clearly contraindicated. In the absence of annular and leaflet calcifications, the anchoring of the prosthesis may be hampered.
To maximize radial strength and optimize anchoring within the aortic unit, we implanted an oversized SAPIEN prosthesis (a 29-mm valve within a 21-mm annulus that would normally require a 23-mm valve) (Edwards Lifesciences). The new transcatheter prosthetic valve was also dilated using an overfilled balloon (filled with 35 mL of contrast instead of the standard 33.5 mL). However the question was whether the anchoring of the valve would be sufficient in a patient without an LVAD who had antegrade heart output.
The development of aortic insufficiency leading to recurrent symptoms in patients with LVADs is known [1]. In a similar situation, Grohmann and associates [3] recently performed percutaneous closure of the aortic valve with an Amplatzer occluder device (AGA Medical, Plymouth, MN). However this device does not guarantee immediate complete resolution of the aortic regurgitation and may lead to hemolysis [3].
In the present case, despite previous LVAD implantation through the left thoracotomy, transapical TAVI was preferred to a transfemoral approach because of severe peripheral vascular disease. When adequate preoperative imaging and a tailored intraoperative strategy are adopted, transapical TAVI remains a safe procedure even in patients with LVADs.
Before applying TAVI to other patients with pure aortic valve regurgitation we need to document that in the long term the anchoring of the prosthesis is sufficient to resist the blood flow that is antegradely ejected from a fully loaded and normally contracting left ventricle in a patient without an LVAD.
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Acknowledgments
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The other members of our TAVI team are Christoph Klein, MD; Marian Kukucka, MD; Alexander Mladenow, MD; Ekatarina Ivanitskaia-Kühn, MD; Natalia Solowjowa, MD; and Katrin Schäfer, CCP. The other members of our assist team are: Thomas Krabatsch, MD, PhD; Evgenij Potapov, MD; Juliane Vierecke, MD. We thank Anne Gale for editorial assistance and Rosemarie Günther for secretarial help.
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References
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- Cowger J, Pagani FD, Haft JW, Romano MA, Aaronson KD, Kolias TJ. The development of aortic insufficiency in left ventricular assist device–supported patients Circ Heart Fail 2010;3:668-674.[Abstract/Free Full Text]
- Pasic M, Dreysse S, Drews T, et al. Improved technique of transapical aortic valve implantation: "the Berlin addition." Ann Thorac Surg 2010;89:2058-2060.[Abstract/Free Full Text]
- Grohmann J, Blanke P, Benk C, Schlensak C. Trans-catheter closure of the native aortic valve with an Amplatzer Occluder to treat progressive aortic regurgitation after implantation of a left-ventricular assist device Eur J Cardiothorac Surg 2011;39:e181-e183.[Abstract/Free Full Text]
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Abstract
Introduction
