Author + information
- Received January 3, 2017
- Revision received February 3, 2017
- Accepted February 3, 2017
- Published online April 3, 2017.
- Norihiko Kamioka, MDa,
- Ateet Patel, MDa,
- Stamatios Lerakis, MDa,
- Ioannis Parastatidis, MDa,
- Jessica Forcillo, MDb,
- Frank Corrigan, MDa,
- Vinod Thourani, MDb,
- Peter Block, MDa and
- Vasilis Babaliaros, MDa,∗ ()
- aDivision of Cardiology, Emory University School of Medicine, Atlanta, Georgia
- bDivision of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
- ↵∗Address for correspondence:
Dr. Vasilis Babaliaros, Emory University Hospital F606, 1364 Clifton Road, Atlanta, Georgia 30322.
A 34-year-old woman with Down syndrome with a history of an atrioventricular canal repair and a mechanical mitral valve replacement came to our hospital due to worsening symptoms of heart failure. Echocardiography and computed tomography imagings revealed a thickened bicuspid aortic valve without significant stenosis and discrete subaortic stenosis (SAS) (mean pressure gradient 67.4 mm Hg) despite resection of subvalvular membrane at her last surgery 11 years prior (Figures 1A and 1B, Online Video 1). Because of her significant cognitive impairment and 2 prior sternotomies, she was deemed a poor surgical candidate. Transcatheter treatment, using the same technique as transcatheter aortic valve replacement, was planned for SAS. Multidetector computed tomography revealed her arterial access was inadequate for traditional transfemoral access or transsubclavian access. Again because of her cognitive impairment, other surgical alternative access (transaortic, transapical, and transcarotid) were not attempted, and therefore the procedure was performed via transcaval access (1,2).
The procedure was performed under general anesthesia in the catheterization laboratory. A Confianza Pro wire (Abbott Vascular, Santa Clara, California) was crossed into the aorta (Figures 1C and 1D, Online Video 2), subsequently exchanged to a Lunderquist wire (Cook Medical, Bloomington, Indiana). After the establishment of transcaval access, a 14-F sheath was advanced from the right femoral vein into the aorta. After balloon valvuloplasty with a 20-mm Z-Med balloon (NuMED, Hopkinton, New York) to confirm the position of the stenosis (Figures 1E, Online Video 3), a 23-mm SAPIEN 3 valve (Edwards Lifesciences, Irvine, California) was deployed covering the stenosis with neither paravalvular leakage nor interference of the mitral valve (Figure 1F, Online Video 4). Aortocaval fistula was closed with a 10/8-mm Amplatzer duct occluder (St. Jude Medical, St. Paul, Minnesota) (Figures 1G and 1H, Online Video 5). The mean gradient had improved to 12.6 mm Hg (Figures 1G and 1H, Online Video 6). The patient was discharged with symptom relief on post-operative day 1.
SAS is often observed in patients with congenital heart disease. Although surgical treatment for SAS remains the gold standard for therapy, reoperation rates are high (3–5). We demonstrated the feasibility of transcatheter treatment as an alternative therapy for SAS in patients with very high surgical risk.
For supplemental videos and their legends, please see the online version of this article.
Dr. Thourani has served as a consultant for Edwards Lifesciences, Maquet, St. Jude Medical, and Sorin; and is a co-founder of and owns stock in Apica. Dr. Block has served as a consultant for Medtronic and St. Jude Medical. Dr. Babaliaros has served as a consultant for Medtronic, Abbott Vascular, and Edwards Lifesciences. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received January 3, 2017.
- Revision received February 3, 2017.
- Accepted February 3, 2017.
- 2017 American College of Cardiology Foundation
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