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Transcatheter Aortic Valve Implantation After Heart Transplantation
Giuseppe Bruschi, Federico De Marco, Jacopo Oreglia, Paola Colombo, Antonella
Moreo, Benedetta De Chiara, Roberto Paino, Maria Frigerio, Luigi Martinelli and Silvio
Klugmann
Ann Thorac Surg 2010;90:66-68
DOI: 10.1016/j.athoracsur.2010.08.021
The online version of this article, along with updated information and services, is
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The Annals of Thoracic Surgery is the official journal of The Society of Thoracic Surgeons and the
Southern Thoracic Surgical Association. Copyright © 2010 by The Society of Thoracic Surgeons.
Print ISSN: 0003-4975; eISSN: 1552-6259.
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Transcatheter Aortic Valve
Implantation After Heart
Transplantation
Giuseppe Bruschi, MD, Federico De Marco, MD,
Jacopo Oreglia, MD, Paola Colombo, MD, PhD,
Antonella Moreo, MD, Benedetta De Chiara, MD,
Roberto Paino, MD, Maria Frigerio, MD,
Luigi Martinelli, MD, and Silvio Klugmann, MD
A De Gasperis Cardiology & Cardiac Surgery Department and
Cardiothoracic Anesthesia and Intensive-Care, Niguarda Ca’
Granda Hospital, Milan, Italy
Conventional cardiac surgical procedures after orthotopic heart transplantation are generally uncommon. We
report the case of a 67-year-old man who had severe
symptomatic aortic stenosis develop 9 years after heart
transplantation. After joint evaluation of the cardiovascular team, transcatheter aortic valve implantation was preferred due to patient medical conditions. The CoreValve
prosthesis (Medtronic, Minneapolis, MN) was inserted
percutaneously into the femoral artery. At 4 months
postoperatively, the patient is asymptomatic in New
York Heart Association functional class II. This case
report provides evidence that transcatheter aortic valve
implantation is safe and suitable for selected patients
with severe aortic stenosis and a history of heart transplantation that must improve allograft function.
(Ann Thorac Surg 2010;90:e66 – 8)
© 2010 by The Society of Thoracic Surgeons
H
eart transplantation (HTx) is a firmly established
surgical approach for the treatment of end-stage
heart failure and has been successfully performed for
more than 30 years. Due to the improvement of surgical
techniques and development of more powerful immunosuppressive agents, long-term survival has significantly
improved during this time. Therefore, an increasing
number of patients have late morbidity after HTx, for
example, valvular disease. Although cardiac retransplantation remains the only definitive therapy for
cardiac allograft failure of any cause, this therapeutic
approach is limited by the scarcity of suitable donor
organs and the associated short-term and long-term
mortality. Thus far, a limited number of reports in smallsized populations have been published on the surgical
management of post-transplant cardiac disease [1]. Coronary artery bypass grafting and tricuspid valve repair or
replacement comprise the majority of the post-transplant
interventions described so far [1, 2]. Very few cases of
aortic valve replacement have been reported in the
literature. In recent years, transcatheter aortic valve implantation has emerged as a safe and effective therapeutic approach for those patients considered at very high or
prohibitive surgical risk. Patients undergoing transcatheter aortic valve implantation are therefore commonly
old and have a high prevalence of severe comorbidities,
such as left ventricular dysfunction, chronic obstructive
pulmonary disease, liver or renal failure, and diffuse
Accepted for publication Aug 12, 2010.
Address correspondence to Dr Bruschi, Cardiology & Cardiac Surgery
Department, Niguarda Ca’ Granda Hospital, Piazza dell’Ospedale Maggiore 3, Milan, 20162, Italy; e-mail: [email protected].
© 2010 by The Society of Thoracic Surgeons
Published by Elsevier Inc
atherosclerosis [3]. We report the case of a man with severe
aortic stenosis and a history of heart transplantation who
was successfully managed with a transcatheter aortic valve
replacement using a self-expanding CoreValve prosthesis
(Medtronic Inc, Minneapolis, MN).
The patient, a 67-year-old Caucasian man was admitted in
March 2010 to our emergency room with acute pulmonary
edema 9 years after orthotopic heart transplantation. He
suffered from chronic hepatitis C. The patient had undergone aortic and mitral valve replacement for rheumatic
valve disease in 1977. He subsequently underwent a successful heart transplantation for severe congestive heart
failure due to dilated cardiomyopathy in 2001, with the
donor being a 58-year-old man who had died of cerebrovascular disease. His postoperative course was characterized by severe right ventricular failure and severe renal
impairment. The patient was discharged on triple-drug
immunosuppression with cyclosporine, azathioprine, and
steroids. At his 12-month follow-up, the patient was asymptomatic with normal cardiac function and mild renal insufficiency. Azathioprine was stopped because of severe leucopenia. In 2004, the patient was treated for an episode of
grade 1B acute heart rejection with echocardiographic evidence of left ventricular dysfunction. In 2007, the patient
was admitted to the hospital with acutely decompensated
heart failure and advanced renal insufficiency requiring
hemodialysis. He had an ejection fraction of 40% and a peak
transvalvular aortic pressure gradient of 18 mm Hg. Coronary angiography revealed diffuse allograft vasculopathy.
The patient was hemodynamically stable and asymptomatic for the next few years, despite a progressive increase in
peak transvalvular aortic pressure gradient up to 68 mm Hg
in 2009.
An echocardiogram obtained during the current hospital admission for acute pulmonary edema showed
severe aortic stenosis and a valve area of 0.5 cm2/m2, with
a peak pressure gradient of 87 mm Hg and an ejection
fraction of 35%. A computed tomographic scan of the
chest and the aortoiliac-femoral axis revealed dilatation
of the ascending aorta (47 mm), with a normal proximal
donor ascending aorta (34 mm), and the iliac and femoral
arteries (Fig 1) of normal size bilaterally. The patient was
jointly evaluated by a multi-disciplinary cardiovascular
team. After joint evaluation, transcatheter aortic valve
implantation was the preferred surgical technique due to
the overall medical conditions. Written informed consent
was obtained from the patient to publish this case report.
The CoreValve ReValving System (Medtronic, Minneapolis, MN) consists of three unique components (ie, a
self-expanding support frame with a tri-leaflet porcine
pericardial tissue valve; a catheter delivery system, which
is 18-French; and a disposable loading system [3, 4]. At
present, valves that are available are 26 and 29 mm in
diameter and this accommodates aortic annulus sizes between 20 and 27 mm.
The procedure was performed in the cardiac catheterization laboratory by our multi-disciplinary cardiovascular team, composed of interventional cardiologists, cardiac surgeons with expertise in hybrid procedures, and
cardiac anesthesiologists. CoreValve implantation was
performed under local anesthesia with mild sedation.
Vascular access was obtained through a percutaneous
right femoral artery puncture with an introducer sheath
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Ann Thorac Surg
2010;90:e66 – 8
CASE REPORT
BRUSCHI ET AL
COREVALVE IMPLANTATION IN HEART TRANSPLANT RECIPIENT
Fig 1. A computed tomographic scan of the chest revealed dilatation
of the ascending aorta (47 mm), with a normal proximal donor ascending aorta (34 mm).
having a size 6-French for hemodynamic monitoring and
landmark aortic angiography. A preloaded pursestring
suture device was implanted in the common femoral
artery (Prostar XL suture device; Abbott Vascular, Abbott
Park, IL) for the 18-French introducer. The surgical technique was described in detail [5]. The 29-mm CoreValve
prosthesis was carefully introduced and retrogradely
implanted under angiographic and fluoroscopic guidance. There was immediate improvement of the patient’s
hemodynamic status. Immediately after valve deployment, we performed an ascending aorta angiogram to
assess coronary artery patency and define the presence
and location of possible paravalvular leaks (Fig 2). The
patient received acetylsalicylic acid (100 mg) both before
and after the procedure (lifelong). A 300-mg loading dose of
clopidogrel was given 24 hours before the procedure, followed by 75 mg daily for 3 months. The standard antibiotic
prophylaxis was given before the procedure and continued for 5 days after the intervention. The patient was
maintained on cyclosporine and steroids. The predischarge echocardiogram revealed a mean transvalvular
aortic pressure gradient of 6 mm Hg, a mild paraprosthetic insufficiency, and an ejection fraction of 36%. On
postoperative day 12, the patient was discharged. At 4
months postoperatively, he is asymptomatic in New York
Heart Association functional class II.
e67
recipients surviving for more than 20 years. As a consequence, an increasing number of patients have late
morbidity after HTx. For example, coronary artery disease and valvular degeneration are late pathologic processes commonly observed in cardiac allografts. There is
a paucity of data in the literature on the surgical management of post-transplant cardiac disease. In 1991, we
believe that Copeland and coworkers [6] were the first to
report a successful mitral valve replacement in a 33-yearold man with severe mitral regurgitation 6 years after
cardiac transplantation. A few additional cases of mitral
valve replacement or repair have been reported. In
contrast, tricuspid valve replacement or repair have been
repeatedly reported after orthotopic heart transplantation [1]. However, allograft arteriosclerosis due to rejection
and other causes include the majority of the post-transplant
interventions [1, 2]. Published data suggest that atrioventricular valve dysfunction is a common finding in patients with a history of heart transplantation. There are
several possible explanations of why atrioventricular
valve dysfunction may occur in HTx recipients, including
multiple biopsies of the right ventricle causing tricuspid
leaflet and chordal injuries, donor myxomatous disease,
and endocarditis. At this point, no data are available on
the incidence of aortic stenosis in heart transplant recipients both from the International Society of Heart and
Lung Transplantation and the United Network for Organ
Sharing (UNOS) registries. We believe that cases of
aortic valve replacement after HTx have been reported
only in anecdotes. We believe that Goenen and colleagues [7] described the first case of an aortic valve
replacement operation for severe aortic regurgitation in a
Comment
Cardiac transplantation is performed worldwide more
than 4,000 times each year with a survival rate after 1 year
that declines at a linear rate of approximately 3.4%, even
well beyond 15 years post-transplant. The median survival of patients undergoing HTx is 10.2 years, with many
Fig 2. Immediately after valve deployment, an ascending aorta angiogram was performed to assess the correct positioning of the device, coronary artery patency, and the occurrence of periprosthetic
regurgitation.
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e68
CASE REPORT
BRUSCHI ET AL
COREVALVE IMPLANTATION IN HEART TRANSPLANT RECIPIENT
28-year-old man 31 months after HTxb. We know of only
one other case of aortic valve replacement that was made
in a 32-year-old woman who had aortic valvular endocarditis develop after heart-lung transplantation [8]. Our
patient presented with symptomatic severe aortic stenosis 9 years after orthotopic cardiac transplantation. We
believe that this is the first reported case of successful
transcatheter aortic valve implantation in a heart transplant recipient.
The introduction of transcatheter aortic valve implantation has recently allowed a minimally invasive approach for those patients considered at very high or
prohibitive surgical risk [3, 4]. Our patient’s risk profile
was characterized by multiple comorbidities and severe
left ventricular dysfunction with an ejection fraction of
35%. The patient was also suffering from chronic hepatitis C infection and end-stage renal disease treated with
hemodialysis.
In summary, this case report provides evidence that
transcatheter aortic valve implantation is safe and suitable for selected high-risk patients with severe aortic
stenosis and a history of heart transplantation and may
represent a viable therapeutic option to extending graft
durability.
Ann Thorac Surg
2010;90:e66 – 8
References
1. Koyanagi T, Minami K, Tenderich G, et al. Thoracic and
cardiovascular interventions after orthotopic heart transplantation. Ann Thorac Surg 1999;67:1350 – 4.
2. Musci M, Loebe M, Wellnhofer E, et al. Coronary angioplasty,
bypass surgery, and retransplantation in cardiac transplant
patients with graft coronary disease. Thorac Cardiovasc Surg
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4. Leon MB, Kodali S, Williams M, et al. Transcatheter aortic
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rationale, device descriptions, early clinical experiences, and
perspectives. Semin Thorac Cardiovasc Surg 2006;18:165–74.
5. Bruschi G, De Marco F, Oreglia J, et al. Percutaneous implantation of CoreValve aortic prostheses in patients with a
mechanical mitral valve. Ann Thorac Surg 2009;88:e50 –2.
6. Copeland JG, Rosado LJ, Sethi G, Huston C, Lee RW. Mitral
valve replacement six years after cardiac transplantation. Ann
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7. Goenen MJ, Jacquet L, De Kock M, Van Dyck M, Schoevardts
JC, Chalant CH. Aortic valve replacement thirty-one months
after orthotopic heart transplantation. J Heart Lung Transplant 1991;10:604 –7.
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Aortic valve replacement for late infective endocarditis after
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Transcatheter Aortic Valve Implantation After Heart Transplantation
Giuseppe Bruschi, Federico De Marco, Jacopo Oreglia, Paola Colombo, Antonella
Moreo, Benedetta De Chiara, Roberto Paino, Maria Frigerio, Luigi Martinelli and Silvio
Klugmann
Ann Thorac Surg 2010;90:66-68
DOI: 10.1016/j.athoracsur.2010.08.021
Updated Information
& Services
including high-resolution figures, can be found at:
http://ats.ctsnetjournals.org/cgi/content/full/90/5/e66
References
This article cites 8 articles, 3 of which you can access for free at:
http://ats.ctsnetjournals.org/cgi/content/full/90/5/e66#BIBL
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