Author + information
- Received April 13, 2016
- Accepted April 21, 2016
- Published online July 25, 2016.
- Omar Issa, DOa,
- Kanna Posina, MDa,
- Ivan Arenas, MDa,
- Esteban Escolar, MDa,
- Angelo La Pietra, MDb and
- Nirat Beohar, MDa,∗ ()
- aColumbia University Division of Cardiology at the Mount Sinai Heart Institute at Mount Sinai Medical Center, Miami Beach, Florida
- bDepartment of Cardiothoracic Surgery at Mount Sinai Medical Center, Miami Beach, Florida
- ↵∗Reprint requests and correspondence:
Dr. Nirat Beohar, Columbia University Division of Cardiology, Mount Sinai Heart Institute, 4300 Alton Road, Miami Beach, Florida 33140.
We present a case of an 81-year-old male patient with recurrent episodes of congestive heart failure. He has a medical history significant for end stage renal disease, ischemic cardiomyopathy, and severe aortic stenosis (peak/mean gradients 64/30 mm Hg, aortic valve area 0.6 cm2) with a recent episode of bacterial native aortic valve endocarditis complicated by pseudoaneurysm (PSA) formation in the ascending aortic root. He received appropriate antibiotic treatment, but was deemed inoperable for any surgical aortic valve replacement or aortic root replacement procedures.
Given his poor prognosis without any intervention and non-operable status, he was evaluated for transcatheter aortic valve replacement. He underwent a pre-procedure computed tomography angiogram of the chest (Figures 1A to 1C) and transesophageal echocardiogram (Figures 1D to 1F) demonstrating severe aortic stenosis, severe aortic regurgitation, and a 6.79 × 3.09 cm PSA arising from the right coronary sinus with flow into the defect both in systole and diastole (Figures 1F and 2A). The position of the neck of the PSA suggested the possibility that deployment of the transcatheter valve may cause fixation of the native coronary leaflet to the aortic wall occluding the PSA.
On the day of the procedure, bilateral femoral artery access was obtained (18-F on right and 6-F on left). A pigtail catheter was inserted into the aortic root and an aortogram was obtained demonstrating flow into the PSA (Figure 2B). The delivery system and the 29 mm Evolut-R CoreValve (Medtronic, Minneapolis, Minnesota) were then passed through the 18-F sheath into the aortic root. Rapid pacing was initiated and the valve was deployed without difficulty. Post-deployment transesophageal echocardiogram images demonstrated resolution of aortic stenosis, with no residual paravalvular leak, and occlusion of the neck and elimination of flow into the PSA (Figures 2C and 2D). The patient tolerated the procedure well and was discharged from the hospital on post-operative day 3 without complications.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received April 13, 2016.
- Accepted April 21, 2016.
- American College of Cardiology Foundation