J INVASIVE CARDIOL 2018;30(7):E62-E63.
Key words: TAVR, native aortic valve regurgitation, transapical approach
A 74-year-old male with ascending aorta repair 15 years ago sparing the native valve and ascending aorta (no aortic graft was used) following type A aortic dissection presented with symptomatic severe native aortic valve regurgitation. Computed tomography (CT) thorax scan showed a residual type A aortic dissection flap starting from the ascending aorta and ending in the distal arch with significant dilatation of the aortic root and ascending aorta (Figures 1A and 1B).
The heart team decided on surgical aortic valve replacement. However, surgery was abandoned due to extensive adhesions between the sternum and the aorta (hostile mediastinum). We therefore elected to perform a transapical transcatheter aortic valve replacement (TAVR). CT imaging showed minimal calcification in the aortic valve leaflets and measurements suggested that a 29 mm Edwards S3 valve (Edwards Lifesciences) would be suitable. Careful antegrade valve crossing was performed using only a standard 0.038˝ wire and a 5 Fr Pigtail catheter under transesophageal echocardiographic (TEE) guidance (Figures 2A and 2B). Following true lumen confirmation, an exchange was made with a super-stiff wire and the valve was successfully deployed slowly at 50/50 position across the native annulus (Video 1) with only mild residual paravalvular aortic regurgitation by aortogram (Video 2) and TEE (Video 3).
Repeat CT of the thorax at 3 months confirmed no change in the size of the dissection flap or aortic dimensions with stable valve position (Figures 1C and 1D) and the patient’s symptoms were much improved.
The vast majority of experience to date with TAVR to treat native aortic valve regurgitation is with self-expanding valves, as they offer better recoil forces, providing more stability in the non-calcified native aortic valve apparatus compared with balloon-expandable valves.
To the best of our knowledge, this is the first reported case of TAVR in a patient with severe native aortic valve regurgitation in the presence of aortic dissection. In our case, the challenge was not only the deployment of a balloon-expandable valve, but also the presence of the aortic dissection flap, which could have been made worse by the wire manipulation. A transapical approach was chosen to avoid any extension of the dissection if a transfemoral or trans-subclavian route were used. The only available transapical valves in our lab are Edwards S3 valves. The CT scan measurement showed that a 29 mm valve (oversized by 20%) would offer more stability to the valve against the aortic annulus to prevent its dislocation. The use of intraprocedure two- and three-dimensional TEE enabled us to confidently identify the exact location of the dissection flap and guide the course of the pigtail catheter, allowing for safe exchange with the super-stiff wire.
The use of balloon-expandable prosthesis in the treatment of native aortic valve regurgitation in the presence of ascending aortic dissection is feasible when there are no surgical options. Proper image guidance and valve over-sizing technique should be utilized to enable the best results.
View the accompanying Imaging Series here.
From Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool, United Kingdom.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
Manuscript accepted March 2, 2018.
Address for correspondence: Hesham K. Abdelaziz, PhD, Blackpool Teaching Hospital, Whinney Heys Road, FY3 8NR, Blackpool, United Kingdom. Email: email@example.com