According to the newly-updated guidelines for the management of patients with valvular heart disease, surgical aortic valve replacement is still the gold standard for treatment of symptomatic patients with severe aortic stenosis (AS).1 However, the guidelines point out that percutaneous aortic valvuloplasty (PAV) might be useful as a bridge to surgery in hemodynamically unstable patients, or as a form of palliation if surgery cannot be performed because of comorbid conditions.1 We report the use of PAV as a bridge to high-risk percutaneous coronary intervention (PCI) in a patient with refractory congestive heart failure, severe aortic stenosis, severe 3-vessel disease, severe left ventricular (LV) dysfunction and significant comorbidities that prohibited aortic valve replacement and coronary artery bypass grafting.
Case Report. A 65-year-old African-American male with severe coronary artery disease, severe AS, LV dysfunction and interstitial lung disease presented to the emergency room with severe shortness of breath. On physical examination, he exhibited bilateral rales, elevated jugular venous pressure, a systolic ejection murmur that radiated to his carotids with a decreased second heart sound, an S3 gallop, decreased carotid upstroke, peripheral edema and cool lower extremities. His heart rate and blood pressure were 113 beats/min and 99/71 mmHg, respectively. A 12- lead electrocardiogram showed new-onset atrial flutter with variable conduction, LV hypertrophy with strain, an old inferior infarct, right-axis deviation and ventricular ectopy. His peak troponin level and pro-BNP were 0.08 and 6,451, respectively. Chest X-ray showed pulmonary edema (Figure 1). Transthoracic echocardiography (TTE) revealed a LV ejection fraction (EF) of 10–15%, peak and mean aortic valve gradients of 51.8 mmHg and 31.2 mmHg, respectively and an estimated aortic valve area of 0.42 cm2 by the continuity equation (Figure 2). Coronary angiography revealed severe 3-vessel coronary artery disease with subtotal occlusion of both the proximal left anterior descending (LAD) and the mid-left circumflex (LCx) arteries with moderate-to-severe stenosis of the ostial right coronary artery (Figure 3). Right heart catheterization showed pulmonary artery pressure of 83/34 mmHg, right atrial pressure of 11 mmHg, pulmonary capillary wedge pressure of 37 mmHg, cardiac output of 4.38 l/minute and a cardiac index of 2.02 l/minute. Single-photon emission computed tomography thallium viability study revealed viable myocardium in all three coronary territories. His perioperative risk was felt to be very high secondary to his pulmonary condition, and was thus prohibitive of aortic valve replacement and coronary bypass grafting. Medical therapy was unsuccessful in alleviating his persistent pulmonary edema and was complicated by worsening renal function and marginal systemic blood pressure. The patient and his family opted to proceed with high-risk percutaneous interventions as the only alternatives to palliative care and end-of-life management. The patient thus underwent PAV utilizing a retrograde approach from the femoral artery via a 14 Fr Daig sheath (St. Jude Medical, Inc., Minnetonka, Minnesota) without any procedural complications (Figure 4). A transvenous pacemaker was inserted via an 8 Fr Daig sheath (St. Jude Medical) placed in the femoral vein. The respective LV end-diastolicpressure, peak and mean gradients across the aortic valve improved from 27 mmHg, 57 mmHg and 45 mmHg before PAV to 15 mmHg, 21 mmHg and 19 mmHg after PAV (Figure 4).
Right heart catheterization post-PAV showed a pulmonary artery pressure of 77/25 mmHg, a right atrial pressure of 16 mmHg, a pulmonary capillary wedge pressure of 15 mmHg, a cardiac output of 4.62 l/minute and a cardiac index of 2.13 l/minute. A post-PAV TTE showed improvement of his aortic valve area to 0.9 cm2, peak and mean aortic valve gradients of 46.2 mmHg and 20 mmHg, respectively, and a LVEF of 30% (Figure 2). He received 4,000 units of intravenous heparin and 60 ml of iodixanol contrast during the valvuloplasty procedure. Protamine was not used, and the arterial and venous sheaths were removed after the activated clotting time dropped to< 120 seconds, and manual pressure was applied over the arterial and venous sites until hemostasis was achieved. His baseline serum creatine was 1.1 mg/dl with a Modification of Diet in Renal Disease (MDRD) creatine clearance of 78 ml/min/1.73 m2. His weight was 221.5 lbs, his height was 69.5 inches, his body surface area was 2.17 m2 and his body mass index was 32.2 kg/m2. His kidney function remained stable postprocedure with a serum creatine in the range of 0.9–1.1 mg/dl. Since his renal function was stable and his heart failure status improved post-PAV, we opted to proceed with PCI during the same hospital admission. He underwent successful PCI to his LAD and LCx 5 days post-PAV using 210 cc of iodixanol contrast (Figure 3). An 8 Fr, 34 cc intra-aortic balloon pump (Datascope, Montvale, New Jersey) was inserted during the PCI, and was weaned off and discontinued successfully within 24 hours. His renal function remained stable post-PCI and his symptoms improved to New York Heart Association (NYHA) Class II before discharge home. Six months after discharge, he continues to lead an enjoyable lifestyle with NYHA Class II heart failure symptoms and no angina.
Discussion. PAV is a procedure first described by Cribier in 1985 in which one or more balloons are placed across the stenotic aortic valve and inflated, fracturing the calcific deposits within the valve leaflets.2 PAV often causes a significant reduction in the patient’s symptoms and a decrease in the transvalvular pressure gradient.2 Unfortunately, the postprocedure valve area rarely exceeds 1.0 cm2. In addition, major complications including stroke, myocardial infarction and aortic regurgitation occur in 10–20% of patients.3,4
Elderly patients with severe aortic stenosis and congestive heart failure do poorly with medical management,5,6 and surgical valve replacement is possible at any age, including octogenarians.7 Therefore, surgical correction, whenever possible, should remain the first line of therapy, even in this patient population.8 However, due to the fact that many of these patients are refused surgery based on their comorbid conditions, PAV has become an accepted approach for palliation of symptoms.9
PAV by-and-large offers temporary relief, with most patients requiring either aortic valve replacement or repeat valvuloplasty in 6 months.10 Rather than a form of palliation, the combined utilization of PAV and PCI in our patient improved his survival from days to > 6 months, as well as his quality of life. It is expected that our patient will likely relapse over the next few months and would benefit from a repeat procedure. A recent report showed that repeat PAV can provide a mean survival rate of approximately 3 years.11 Although several reports in the literature describe the combined use of PAV and PCI in elderly patients denied surgery,12–16 ours is the first to show the use of PAV as a bridge to allow PCI in a critically ill patient, thereby extending his life and improving its quality. We therefore strongly believe that under the right circumstances, PAV can be utilized in a manner that is not a bridge towards valve replacement or a palliative therapy, but rather a part of complex therapy aimed at prolonging life.
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