Author + information
- Received June 20, 2016
- Accepted July 14, 2016
- Published online October 24, 2016.
- Rodrigo Bagur, MD, PhDa,∗ (, )
- Patrick J. Teefy, MDa,
- Bob Kiaii, MDb,
- Aashish Goela, MDc,
- Adam Greenbaum, MDd and
- Michael W.A. Chu, MDb
- aDivision of Interventional Cardiology, Heart Team, University Hospital, London Health Sciences Centre, Western University, London, Ontario, Canada
- bDivision of Cardiac Surgery, Heart Team, University Hospital, London Health Sciences Centre, Western University, London, Ontario, Canada
- cDepartment of Radiology, Heart Team, University Hospital, London Health Sciences Centre, Western University, London, Ontario, Canada
- dCenter for Structural Heart Disease, Division of Cardiology, Henry Ford Health System, Detroit, Michigan
- ↵∗Reprint requests and correspondence:
Dr. Rodrigo Bagur, Division of Cardiology, London Health Sciences Centre, Department of Medicine, Western University, 339 Windermere Road, University Hospital, London, Ontario N6A 5A5, Canada.
A 77-year-old man presented with severe symptomatic aortic stenosis. He had multiple comorbidities, including significant chronic obstructive pulmonary disease and severe peripheral vascular disease. Doppler echocardiography demonstrated a heavily calcified and severely stenotic aortic valve, with a mean gradient of 45 mm Hg and a left ventricular ejection fraction of 60%. Coronary angiography showed no significant coronary disease. On the basis of his intermediate pre-operative risk assessment (Society of Thoracic Surgeons score 4.7%), the heart team considered the patient most suitable for a transcatheter-based approach. Importantly, transfemoral access was unsuitable because of occlusion of the left iliac artery and a small minimal luminal diameter (4.1 mm) of the right femoral artery. Given the patient’s lung condition, the team decided to perform transcatheter aortic valve replacement using the transcaval approach.
The procedure was performed in a hybrid operating room by our heart team using right caval-aortic access, as previously described (1,2). Simultaneous aortic and caval angiography was performed to guide the crossing site puncture (Figure 1A, Online Video 1). Notably, pre-procedural computed tomography was used to accurately select the caval-aortic crossing point (Figures 1B and 1C, Online Video 2) with the least calcified segment of the adjacent aortic wall, no interposed structures, and fluoroscopic landmarks related to lumbar vertebrae (Figures 1D to 1H, Online Videos 3 and 4). A 20-F extra-large Check-Flo (Cook Medical, Bloomington, Indiana) introducer sheath was inserted (Figure 1I, Online Video 5); then, balloon aortic valvuloplasty was performed with a 22 × 40 mm balloon. Using a computed tomography–guided sizing nomogram, a medium-size ACURATE neo (Symetis, Ecublens, Switzerland) aortic bioprosthesis was selected for implantation (Figure 1J, Online Video 6). The caval-aortic path was closed using a 10/8-mm Amplatzer Duct Occluder (St. Jude Medical, St. Paul, Minnesota) (Figures 1K to 1N, Online Videos 7, 8, and 9). Several aortograms were obtained to assess shunt to the retroperitoneal space, which was judged as “type 2” according to the Lederman classification (2) (Figure 1L, Online Video 10). The patient recovered well without complications and was discharged home 6 days after transcaval transcatheter aortic valve replacement. Doppler transthoracic echocardiography revealed peak and mean gradients of 8 and 3 mm Hg, respectively, and a trace paravalvular leak. At 3-month follow-up, the patient was in New York Heart Association class I or II, and computed tomography showed absence of shunt or fistula (Figure 1O, Online Video 11).
The present case reports the first transcaval transcatheter aortic valve replacement performed in Canada and the first in North America using the ACURATE neo aortic bioprosthesis. This newly available access-site approach further expands the heart team’s options, enabling treatment of a special subset of patients presenting with unique anatomic features.
The authors thank Drs. Pantelis Diamantouros, Daniel Bainbridge, and Luc Dubois for their help during the procedure. They also thank Dr. Robert J. Lederman and Marcus Y. Chen of the National Heart, Lung, and Blood Institute, National Institutes of Health (Bethesda, Maryland), for their assistance with procedural suitability and imaging planning.
For supplemental videos and their legends, please see the online version of this article.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received June 20, 2016.
- Accepted July 14, 2016.
- 2016 American College of Cardiology Foundation
- Greenbaum A.B.,
- O’Neill W.W.,
- Paone G.,
- et al.
- Lederman R.J.,
- Babaliaros V.C.,
- Greenbaum A.B.