Author + information
- Fausto Castriota, MD,
- Roberto Nerla, MD∗ (, )
- Antonio Micari, MD, PhD,
- Angelo Squeri, MD and
- Alberto Cremonesi, MD
- ↵∗Interventional Cardiovascular Unit GVM Care & Research, Maria Cecilia Hospital, Via Corriera 1, 48033 Cotignola, Ravenna, Italy
Chronic kidney disease is a prognostically relevant predictor of periprocedural acute kidney injury after transcatheter aortic valve replacement (TAVR). (1). In spite of being related to multiple possible causes (i.e., anemia, hypotension, heart failure, age, diabetes), the administration of contrast dye before and during TAVR procedure plays a crucial role. Several strategies aimed at reducing the amount of contrast used during TAVR have been proposed (2,3) but no one was able to completely abolish the use of contrast dye.
We have recently introduced in our clinical practice a standardized protocol for performing transfemoral TAVR without any use of contrast dye in patients with severe chronic kidney disease. All consecutive patients with severe renal dysfunction (i.e., glomerular filtration rate ≤30 ml/min) referred to our tertiary center from spoke hospitals (where a coronary angiogram to rule out coronary artery disease had been already performed) were treated with a contrast-zero approach and prospectively included in a clinical database.
As a part of routine pre-procedural assessment, no patients included in the study underwent angio computed tomography (CT). A no-contrast CT was performed to localize and quantify the degree of aortic calcification, the amount and the distribution of calcium in iliofemoral vessels. In all patients CO2 angiography (Angiodroid injection system, Angiodroid Srl, San Lazzaro, Bologna, Italy; 30 to 50 ml of CO2 per injection, injection pressure set 40 mm Hg over patient’s systolic blood pressure) was performed the day before the procedure.
TAVR procedure was performed in general anesthesia. Intraprocedural transesophageal echocardiology (3-dimensional views: short-axis, midesophageal, 40° to 70°; long-axis, midesophageal, 110° to 135°) was used for annulus sizing. Valve final sizing was determined as per synthesis of all the available information (i.e., transesophageal echocardiology, no-contrast CT, calcification on fluoroscopy). To find the fluoroscopic working view for valve deployment, if needed, 3 different pig-tail catheters were positioned in the aortic root (2 from the same large sheath), 1 for each coronary cusp (Figure 1).
From November 2016 to September 2017 a total of 20 patients (age 81.8 ± 5.4; 60% males; glomerular filtration rate 27.4 ± 3.1 ml/min; Society of Thoracic Surgeons mortality score 14.3 ± 4.5) were included in the contrast-zero population. Following CO2 angiographic pictures analysis, femoral access was used in all patients. All procedures were successfully performed with no use of contrast dye. All available TAVR devices were used (Evolut R, Medtronic, Minneapolis, Minnesota, n = 12; Acurate Neo, Boston Scientific, Natick, Massachusetts, n = 4; Lotus Valve, Boston Scientific, Massachusetts, n = 4). Pre-dilation was used in 5 cases (25%), whereas post-dilation was required in 4 cases (20%).
Final aortic regurgitation was not more than mild in 100% patients. Two patients died during hospital stay (gut bleeding in labile international normalized ratio, no varices; respiratory failure in known chronic obstructive pulmonary disease). There were no major vascular complications. One patient developed acute pericardial effusion during the procedure because of wire perforation of left ventricle outflow tract; successful pericardial drainage was performed and the procedure was still carried out without use of any contrast dye. The implantation of a permanent pacemaker before discharge was required in 3 cases (15%). No patients developed acute kidney injury at 48 h or at discharge.
Although obtained in a small population, our data show that a contrast-free TAVR approach in patients with advanced chronic kidney disease is feasible and could be considered as a valid strategy to avoid acute kidney injury after TAVR with a large variety of devices. The use of CO2 angiography is fully reliable to assess peripheral vessels diameters and patency, whereas no-contrast CT is able to depict vessel calcifications: combining both information was crucial to observe no major vascular complications. Our approach, including a 3-dimensional measurement of annulus size, was helpful to achieve a satisfactory result with respect to frequency and severity of post-deployment aortic regurgitation. Finally, even in presence of a complication (left ventricular perforation) there was no need for contrast injection and TAVR procedure was successfully carried out as previously planned.
Limitations and potential pitfalls of this strategy should be noted. First, the impact of general anesthesia in such a high-risk population could be relevant, thus making mandatory maintaining adequate blood pressure values during the procedure to reduce kidney hypoperfusion. Second, the risk of coronary occlusion cannot be fully appreciated before or during the procedure; electrocardiogram changes, patients’ symptoms, and Doppler flow in left main assessed at transesophageal echocardiology can be used only as surrogate measures.
Please note: Dr. Castriota is a proctor of Lotus valve implantation for Boston Scientific. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2018 American College of Cardiology Foundation
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