Author + information
- Received February 1, 2017
- Accepted March 9, 2017
- Published online June 5, 2017.
- Edgar Lik-Wui Tay, MBBS∗ (, )
- William Kok-Fai Kong, MBBS,
- James Wei-Luen Yip, MBBS,
- Ting Ting Low, MBBS and
- Jimmy Kim-Fatt Hon, MBBS
- ↵∗Address for correspondence:
Dr. Edgar Lik-Wui Tay, National University Heart Centre, Tower Block Level 9, 1E Kent Ridge Road, Singapore 119228, Singapore.
A 38-year-old woman with suspected Marfan syndrome underwent an ascending aorta aneurysm repair with a David I valve-sparing procedure using a 26-mm Gelweave graft (Vascutek, Inchinnan, United Kingdom) 5 years previously (1). Unfortunately, she developed progressively severe aortic valve regurgitation (AVR) (Figure 1A). While awaiting surgical repair, she experienced an acute middle cerebral artery stroke. During this complication, the patient had repeated episodes of recurrent hypotension and could not be weaned off mechanical ventilation. The heart team recommended transcatheter aortic valve replacement (TAVR) over open surgery because of the risk for hemorrhagic conversion.
Computed tomography confirmed that transfemoral access was possible. The perimeter of the native annulus measured 80 mm, and the Gelweave graft diameter was 26 mm, with a length of 8 cm (Figures 2A and 2B). Key challenges were 1) choice of TAVR bioprosthesis; 2) sizing; and 3) lack of calcification and marked device mobility from AVR.
We chose the Evolut R 29-mm valve (Medtronic, Minneapolis, Minnesota) after testing the valve in a simulated 26-mm tube to ensure that the functional part of the valve was not impinged, as both the distal and proximal portions of the Evolut R would be restrained in this 8-cm graft. The pigtail could not be maintained in the aortic root, making visualization difficult. Also, contrast opacification was barely adequate despite 40 ml of contrast and rapid pacing (Figure 3A). Fortunately, live 3-dimensional transesophageal echocardiography enabled us to confidently visualize and position the valve (Figures 1C and 1D) and assess it pre-release. Also, the repositionable nature of the device allowed us a second chance when the device popped into the ascending aorta. We avoided a high implantation to avoid left main coronary artery occlusion. Good positioning was finally achieved with transesophageal echocardiography, contrast opacification, and rapid pacing to 160 beats/min. Good restoration of diastolic pressure with trivial paravalvular leak was seen after valve deployment. The patient was extubated successfully after 3 days.
To our knowledge, this is the first report of TAVR in a patient with severe AVR after a valve-sparing ascending aortic repair. Although ours was a situation involving AVR, the techniques described for native AVR (e.g., oversizing) do not fully apply here (2). Also, our situation was unlike a valve-in-valve procedure, because the Gelweave graft was long and constrained the entire frame of the TAVR valve. Ex vivo simulation is important, as is the use of 3-dimensional transesophageal echocardiography to enable best results.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received February 1, 2017.
- Accepted March 9, 2017.
- 2017 American College of Cardiology Foundation
- David T.E.
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- Piccolo R.,
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- et al.