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Persistent Native
Aortic Valve Function
after Transcatheter Aortic Valve Replacement
Vikas Singh, MD
Claudia A. Martinez, MD,
FSCAI
William W. O’Neill, MD, FSCAI
Alan W. Heldman, MD, FSCAI
A
59-year-old man who had been treated with radiation for Hodgkin’s lymphoma 35 years earlier developed emphysema and symptomatic severe aortic stenosis with New York Heart Association (NYHA) functional class IV
symptoms and episodes of near-syncope. After a median sternotomy, the aorta was
reported to be unfavorable for clamping, and valve surgery was aborted. Computed tomography of the chest showed severe calcification of the ascending aorta, aortic
arch, and aortic valve (Fig. 1). Figure 2 shows the aortic valve leaflets preprocedurally.
Transcatheter aortic valve replacement (TAVR) was performed. A 26-mm Edwards
Sapien ® valve (Edwards Lifesciences Corporation; Irvine, Calif ) was implanted by
means of a transfemoral approach. After valve deployment, transesophageal echocar-
Fig. 1 Computed tomogram
of the chest shows extensive
calcification of the ascending
aorta, aortic arch, and aortic
valve. Calcified pericardium
is also noted.
Section Editor:
Raymond F. Stainback, MD,
Department of Adult
Cardiology, Texas Heart
Institute at St. Luke’s
Episcopal Hospital, 6624
Fannin St., Suite 2480,
Houston, TX 77030
From: Cardiovascular
Division, University of Miami
Hospital, Miller School of
Medicine, Miami, Florida
33136
A
B
Dr. O’Neill is now at
Henry Ford Hospital,
Detroit, Michigan.
Address for reprints:
Vikas Singh, MD,
University of Miami
Miller School of Medicine,
1400 NW 12th Ave., Suite
1179, Miami, FL 33136
E-mail:
[email protected]
© 2013 by the Texas Heart ®
Institute, Houston
364
Fig. 2 Preprocedural transesophageal echocardiogram shows the native aortic valve leaflets during
A) systole and B) diastole.
Click here for real-time motion image: Fig. 2.
Persistent Native Aortic Valve Function after TAVR
Volume 40, Number 3, 2013
A
B
Fig. 3 Transesophageal echocardiograms show the Edwards Sapien ® aortic valve (arrows) and the native leaflets (arrowheads) A) open in
systole and B) closed in diastole.
Click here for real-time motion image: Fig. 3.
diograms showed that the native leaflets were displaced
against the aortic wall; however, there was persistent
opening and closing of the native left and posterior coronary cusps (Fig. 3). In systole, the native aortic valve
commissure had an opening of 0.63 cm 2 as measured
by planimetry. There was mild posterior paravalvular
regurgitation at this commissure during diastole. The
prosthetic valve functioned normally. Despite the appearance of incomplete apposition to the entirety of the
aortic annulus, the prosthesis was in stable position with
minimal paravalvular regurgitation (Fig. 4). The patient’s recovery was uncomplicated. One month later, he
was in NYHA functional class II status, and transthoracic echocardiograms showed a well-seated valve with
mild insufficiency.
Comment
To our knowledge, a significant persistent lumen in a
native aortic valve after TAVR has not been reported.
Mediastinal radiotherapy is an established risk factor for
the development of a variety of cardiovascular diseases that affect the coronary arteries, pericardium, myocardium, conduction system, and myocardial valves.1,2
The prevalence of radiation-associated cardiac disease
is increasing because of prolonged survival after mediastinal irradiation. Aortic stenosis, a less well-understood complication that can occur 15 to 20 years after
radiation therapy, is attributed to diffuse fibrosis with
or without calcification.3 Conventional surgical aortic
valve replacement in patients with radiation-associated
Texas Heart Institute Journal
Fig. 4 Transesophageal echocardiogram with color-flow Doppler
shows trace-to-mild paravalvular regurgitation through the native
valve (arrow) after deployment of the Edwards Sapien ® aortic
valve.
Click here for real-time motion image: Fig. 4.
mediastinal disease carries increased risk,4 and many patients with this condition are considered for TAVR. A
better understanding of how TAVR performs in previously irradiated structures is needed.
References
1. Hull MC, Morris CG, Pepine CJ, Mendenhall NP. Valvular
dysfunction and carotid, subclavian, and coronary artery disease in survivors of Hodgkin lymphoma treated with radiation therapy. JAMA 2003;290(21):2831-7.
Persistent Native Aortic Valve Function after TAVR
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2. Wethal T, Lund MB, Edvardsen T, Fossa SD, Pripp AH,
Holte H, et al. Valvular dysfunction and left ventricular
changes in Hodgkin’s lymphoma survivors. A longitudinal
study. Br J Cancer 2009;101(4):575-81.
3. Veinot JP, Edwards WD. Pathology of radiation-induced
heart disease: a surgical and autopsy study of 27 cases. Hum
Pathol 1996;27(8):766-73.
4. Chang AS, Smedira NG, Chang CL, Benavides MM, Myhre
U, Feng J, et al. Cardiac surgery after mediastinal radiation:
extent of exposure influences outcome. J Thorac Cardiovasc
Surg 2007;133(2):404-13.
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Persistent Native Aortic Valve Function after TAVR
Volume 40, Number 3, 2013