Download A Combined Transcatheter Aortic Valve-in

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JACC: CARDIOVASCULAR IMAGING, VOL. 8, NO. 7, 2015
Letters to the Editor
JULY 2015:863–9
Please note: Dr. Miglioranza has received a post-graduate grant from CAPES, a
ila
has
Brazilian governmental agency for post-graduate support. Dr. Miha
received a research grant from the European Association of Cardiovascular
Imaging. Drs. Muraru and Badano have received equipment grants from and
served on the speakers bureau for GE Healthcare. All other authors have reported that they have no relationships relevant to the contents of this paper to
disclose.
artery origin and proximal left anterior descending
artery from the pulmonary artery were 8.7 mm and
11.9 mm, respectively. Coronary artery relational
anatomy was felt to be favorable for intervention
with combined transcatheter aortic ViV and TPVI
(Figure 1A).
REFERENCES
Using standard techniques, a 26-mm transcatheter
1. Vahanian A, Alfieri O, Andreotti F, et al. Guidelines on the management
of valvular heart disease (version 2012): Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology,
European Association for Cardio-Thoracic Surgery. Eur Heart J 2012;33:
2451–96.
2. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the
Management of Patients With Valvular Heart Disease: a report of the American
College of Cardiology/American Heart Association Task Force on Practice
Guidelines. J Am Coll Cardiol 2014;63:e57–185.
3. Cohen GI, White M, Sochowski RA, et al. Reference values for normal adult
transesophageal echocardiographic measurements. J Am Soc Echocardiogr
1995;8:221–30.
4. Colombo T, Russo C, Ciliberto GR, et al. Tricuspid regurgitation secondary
to mitral valve disease: tricuspid annulus function as guide to tricuspid valve
repair. Cardiovasc Surg 2001;9:369–77.
5. Chopra HK, Nanda NC, Fan P, et al. Can two-dimensional echocardiography
and Doppler color flow mapping identify the need for tricuspid valve repair?
J Am Coll Cardiol 1989;14:1266–74.
aortic valve replacement (Sapien-XT, Edwards Lifesciences) was successfully undertaken within the
aortic prosthesis. Post-deployment echocardiographic
assessment demonstrated normal valve function. A
noncontrast rotational angiogram of the cardiac and
vascular structures was then performed, and images
were matched with previously performed CT reconstructions of the pulmonary conduit. Coregistration using known skeletal landmarks enabled overlay
of 3D images onto live fluoroscopy to guide transcatheter pulmonary valve placement. An exchangelength stiff guidewire was placed in the left lower
lobe pulmonary artery using a balloon wedge catheter,
and serial balloon dilations of the pulmonary conduit
were performed using 18- and 22-mm balloons with
simultaneous left coronary angiography demonstrating no coronary–conduit interaction. A 22-mm
A Combined Transcatheter Aortic
diameter balloon-in-balloon “BIB” catheter (NuMed,
Valve-in-Valve and Pulmonary Valve
Hopkinton, New Jersey) with a mounted stent (Pal-
Implantation
maz-XL-4010, Cordis, Bridgewater, New Jersey) was
delivered via a 14-Fr Mullins sheath into the pulmonary conduit. This was used to expand the homograft
Patients with surgically treated congenital cardiac
conduit and prepare a landing zone to minimize future
disease increasingly survive into adulthood and face
risk of transcatheter pulmonary valve stent fracture.
the need for repeat sternotomies for senescent pros-
Fluoroscopic and 3D CT overlay facilitated accurate
thetic valves and conduits. This poses increased risk
positioning and deployment of the stent. The stent was
of chest re-entry injury, and alternatives to redo
then post-dilated using a 22-mm balloon, and no stent
median sternotomy are important. Although trans-
recoil was noted. A 22-mm transcatheter pulmonary
catheter aortic valve-in-valve (ViV) and transcatheter
valve was then successfully deployed using a 22-mm
pulmonary valve implantation (TPVI) (Melody valve,
delivery system (Ensemble delivery system, Med-
Medtronic, Minneapolis, Minnesota) have both been
tronic) within the landing zone created by the stent
separately described (1–3), we describe a combination
(Figures 1B and 1C). The peak-to-peak catheter right
of aortic ViV and TPVI utilizing 3-dimensional (3D)
ventricular outflow tract (RVOT) gradient was reduced
computed tomography (CT) fluoroscopic coregistra-
to 5 mm Hg. Transesophageal echocardiography
tion to aid procedural execution. A 24-year-old man
showed normal valve function with mild regurgita-
with congenital bicuspid aortic stenosis, prior Ross
tion. The patient was dismissed from the hospital on
procedure, re-replacement of the right ventricle–
day 2 with a mean transaortic gradient of 21 mm Hg,
pulmonary artery homograft, ascending aortic aneu-
and 11 mm Hg across the RVOT, with no demonstrable
rysm repair, and aortic valve replacement (25-mm
regurgitation.
Perimount
bioprosthesis,
Edwards
Lifesciences,
This presentation is unique in that this was a young
Irvine, California) was referred for symptomatic
adult with 3 previous median sternotomies within a
aortic and pulmonary conduit stenoses. Aortic valve
period of 6 years, and efforts to avoid a repeated me-
mean gradient was 52 mm Hg, and mean pulmonary
dian
conduit gradient was 38 mm Hg. CT demonstrated
assessment and 3D imaging were essential to proce-
pulmonary conduit stenosis and an aortic annular
dural planning and execution. Although annular
area of 360 mm 2 (annular dimensions 21.9 mm calcification and radiographic signatures of prosthetic
21.5 mm). The distances of the right coronary
valves can often serve as fluoroscopic markers and
sternotomy
were
critical.
Multidisciplinary
JACC: CARDIOVASCULAR IMAGING, VOL. 8, NO. 7, 2015
Letters to the Editor
JULY 2015:863–9
F I G U R E 1 Pre- and Post-Intervention 3D Surface-Rendered Images of Aortic and Pulmonary Outflow Tracts
(A) Surface-rendered images of the aorta (Ao) and right ventricular outflow tract (RVOT) demonstrating favorable relational anatomy of
reimplanted coronary buttons to the RVOT/main pulmonary artery (MPA). The inset shows a distance of w8.8 mm between the RVOT and right
coronary artery. (B) Lateral projection with fluoroscopic overlay during inflation of the outer balloon for delivery of transcatheter pulmonary
valve (red arrow); transcatheter aortic valve in aortic position (blue arrow). (C) Final surface 3-dimensional (3D) rendered image of the
transcatheter aortic and pulmonary valves. PV ¼ pulmonary vein; RCA ¼ right coronary artery.
assist with valve positioning and deployment during
REFERENCES
transcatheter valve–ViV implantation, these are not
1. Eggebrecht H, Schafer U, Treede H, et al. Valve-in-valve transcatheter
always available or optimal for procedural guidance.
The use of 3D CT fluoroscopic coregistration using
skeletal landmarks can significantly improve the accuracy of valve positioning and procedural success.
aortic valve implantation for degenerated bioprosthetic heart valves. J Am
Coll Cardiol Intv 2011;4:1218–27.
2. Meadows JJ, Moore PM, Berman DP, et al. Use and performance of the
Melody Transcatheter Pulmonary Valve in native and postsurgical, nonconduit right ventricular outflow tracts. Circ Cardiovasc Interv 2014;7:
374–80.
Saurabh Sanon, MD
Allison K. Cabalka, MD
Rakesh M. Suri, MD
Donald Hagler, MD
Charanjit S. Rihal, MD*
From Plaque Morphology to Ischemia:
*Division of Cardiovascular Diseases
Pushing the Limits of Spatial Resolution
3. Dvir D, Webb J, Brecker S, et al. Transcatheter aortic valve replacement for
degenerative bioprosthetic surgical valves: results from the global valve-invalve registry. Circulation 2012;126:2335–44.
Mayo Clinic
200 First Street South West
Rochester, Minnesota 55905
E-mail: [email protected]
http://dx.doi.org/10.1016/j.jcmg.2015.05.002
Please note: Dr. Rihal has received research funding from Edwards Lifesciences.
All other authors have reported that they have no relationships relevant to the
contents of this paper to disclose.
We read with interest the paper by Park et al. (1)
concerning the association between certain atherosclerotic plaque characteristics (APCs), depicted by
coronary computed tomography angiography (CTA)
and the presence of ischemia by invasive fractional flow reserve (FFR). The study addressed the
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