Download manuscrit valve in valve (1)

Percutaneous Valve in aortic valve bioprosthesis through a
carotid prosthesis
Authors:
1)Corresponding author :
BENHALLA Hanane ,Doctor,MD
Brussels heart center –Brussels,Belguim
Contact phone :00212661885875/Email :[email protected]
Address: 23 lotissement lamia ,Bourgogne Casablanca .Morocco
2) SOREA Camelia ,Doctor,MD
Brussels heart center –Brussels,Belguim
Keywords :
valve in valve ,carotid bioprosthesis ,percutaneous aortic valve
Abstact :
In recent years, transcatheter aortic valve implantation has become an emerging alternative
for high-risk patients with severe aortic stenosis. A promising new indication in this
technology could be the interventional treatment of degenerated bioprosthesis ,a vascular
prosthesis access was used in our case to facilitate the procedure in the absence of an
adequate vascular acces for no refusing the patient.
Learning objective :
Patient selection for the TAVI without adequate acess remain crucial ,and this a case how we
can face this situation.
Introduction
The first percutaneous aortic valve replacement has been performed by Dr. A. Cribier in
2002 , opening a new therapeutic approach to patients at high surgical risk for conventional
operation by sternotomy.
In a short time , there has been an improvement of the material and a simplification of the
procedure,the surgical approach used and the implantation technique .However patients
selection remains crucial , We describe a percutaneous aortic valve implantation(a
CoreValve bioprosthesis) in a degenerate bioprosthesis without an adequate vascular acces,
and who we decide a carotid bioprosthesis in per operative procedure.
Clinical case:
Patient of 83 years who has an history of ischemic heart disease with moderate left
ventricular dysfunction ( ejection fraction 45% ) , he received in 2009 a replacement of his
aortic valve bioprosthesis (with a Mitroflow No. 23) that has gradually become stenotic .
The patient had at his admission a dyspnea stage IV refractory to medical treatment with
severe.decompensation ,the logistqiue EuroSCORE was calculated at 36%.
Preoperative echocardiographic data objectified an aortic stenosis with a mean gradient of
53 mmHg , a maximum gradient of 87 mmHg and an aortic area calculated by the continuity
equation 0.8 cm2 .
Preoperative CT angiography showed a diameter of the common iliac artery of 5 mm and a
diameter of the left iliac artery to 5 mm , the diameter of the sub clavian arteries was 6 mm ,
and retained the first carotid as the only solution with a biprosthesis to facilitate the
procedure.
The intervention consisted of a first right carotid positioning with a bioprosthetic in Dacron to
facilitate the introduction of CoreValve , and a right femoral small acces (5 french) useful for
the introduction of the probe aortography during the procedure.
the Figure No [ 1,2 ] shows the development of the valve in valve ( CoreValve model 23)
directly without prior dilation with at the time of deployment of the valve in a valve ;a
localization 4 mm below the position considered ideal for implantation,(figure N [ 3 ]) this may
explains that in the immediate postoperative a persistent transaortic mean gradient at 20
mm Hg , a maximum gradient of 42 mm Hg and a 1.1 cm2 surface .
Post-operative follow was under inotropes drugs with extubation the first day after the
procedure. The improvement of signs of heart failure was observed in the first week for the
patient..
The patient was seen one month after the procedure with a clear clinical improvement and
regression of his episodes of cardiac decompensation .
Discussion:
This patient therefore had aortic stenosis in already a bioprosthesis with a refractory
dyspnea .
It remains to determine if the patient is technically affordable percutaneously with
angiographic evaluation of vascular axes with the aortic annulus , the ascending aorta and
the distance with the coronary arteries ostias by ( transthoracic echocardiography , CT -scan)
the size of the ring can vary significantly depending on the selected imaging and should not
be generally less than 18 mm or greater than 29 mm as well as close to the aortic annulus to
coronary ostia witch remains crucial .
The incision in our case of the right primitive carotid artery was facilitated by the introduction
of a prosthesis carotid in Dacron , which is according to our knowledge a first procedure [ 3 ].
Modine and all, reported 12 cases of aortic valve implantation by a carotid acces without
prosthesis , one patient had a transient ischemic stroke .So electroencephalogram
monitoring in parallel to procedure seems necessary to monitor cerebral perfusion [3 ]
The median time for the implantation of the valve in valve is still about 120 min in the
European register[ 3 ] ,for our case, it was 180 min with a fluoroscopy time of 36 min
explained by the initial implatation of the carotid prosthesis .
For the valve in valve procedure the most common risk is the worse deployment of the
percutaneous valve secondary to calcifications usually present on the bioprosthesis
especially if it is asymmetric [ 3 ],There is also often the need to implant a permanent
pacemaker ( 5.7 % to 20 % for Corvalve ) which remains the most common event described
in the first 30 days with a positioning 2 at 6 mm below the base of the aortic annulus ,witch
may interfere with the atrioventricular node , located very close to the aortic region and submembranous septum [ 3,4 ]
CONCLUSION: Percutaneous aortic valve replacement on degenerated bioprosthesis is a
new option as an alternative to surgery for patients at high surgical risk. This technique
allows hemodynamic and functional improvement that persists in the medium term . Patient
selection and multidisciplinary approach remains critical , with also a careful analysis of
surgical approaches and vascular acces to guess complications in per operative procedure..
Acknowledgments
Disclosures:
:None
The Authors declar that there is no conflict of interest'
References:
1 / W.Henn Lucas , MD . ; Raj R Makkar , MD, FACC, FSCAI . ; P.Fontana Gregory , MD
Valve in valve TAVI for Degenerated surgical prostheses
Cardiac interventions today - August 2010
2) Modine T, Sudre A, Delhaye C , Fayad G, Lemesle G, Collet F, Koussa M.
Transcutaneous aortic valve implant using the left carotid access : Feasibility and early
clinical outcomes .
Ann Thorac Surg . 2012 May , 93 :1489 -94
3) Thomas Modine , MD * , Gilles Lemesle , MD, Richard Azzawi , MD, Arnaud Sudre , MD
Aortic valve implant with the CoreValve ReValving System via left carotid artery access:
First case report
J Thorac Cardiovasc Surg 2010; 140:928-929
4) Ng AC, van der Kley F, Delgado V , M Shanks , RJ van Bommel , of Weger A, Tavilla G,
Holman ER , Schuijf JD, van de Veire NR Schalij MJ , Bax JJ
Percutaneous valve -in- valve procedure for severe paravalvular regurgitation in aortic
Bioprosthesis
JACC Cardiovasc Imaging. 2009 Apr ; 2 :522-3 .
Figure Legends :
Figure 1 :CT angiography viewing the aortic prosthetic ring with calcifications befor and after
the endovalve implantation
Figure 2 :Angiographic view of the introduction of the percutaneous aortic valve on the
degenerate bioprosthesis and the result in the Chest radiograph.
Figure 3 : CT scann of the endovalve relative to the ring of the bioprosthesis
Figure 1 :CT angiography viewing the aortic prosthetic ring with calcifications befor and after
the endovalve implantation
Figure 2 :Angiographic view of the introduction of the percutaneous aortic valve on the
degenerate bioprosthesis and the result in the Chest radiograph.
Figure 3 : CT scann of the endovalve relative to the ring of the bioprosthesis