TAVI utilized in atypical anatomy to mitigate high-risk reoperation.
Central Message.
TAVI can be utilized safely in complex and carefully selected cases with appropriate planning as an alternative to high-risk reoperation.
A 76-year-old man presented to hospital with heart failure (institutional review board approval was not required; consent waived). He had undergone comprehensive aortic root and valve repair (CARVAR), which includes a reducing sinotubular junction (STJ) ring, aortic annuloplasty with ring/felt, and leaflet modification/augmentation using pericardium, and 2-vessel bypass 11 years prior in South Korea. No operative report was available. Blood pressure was 140/50 mm Hg. Blood work demonstrated N-terminal pro-B type natriuretic peptide of 1185 pg/mL and normal troponin, hemoglobin, and creatinine levels. Echocardiogram demonstrated moderate aortic stenosis and at least moderate eccentric aortic insufficiency (AI) with prolapse of the left coronary cusp. Aortic valve area was calculated at 0.73 cm2 with peak and mean gradients of 41 and 23 mm Hg, respectively. The left ventricular ejection fraction was 65%. Coronary angiogram demonstrated a patent coronary graft of the left internal thoracic artery in a Y-configuration; AI was severe on aortogram. Aortic dimensions were confirmed by computed tomography and the procedure was planned utilizing 3mensio Structural Heart imaging software (Figure 1). Further measurements utilized in the planning are provided in Table E1. The options for intervention included transcatheter aortic valve implantation (TAVI) versus high-risk reoperation, likely root and valve replacement. After discussions between patient and heart team, literature review, and virtual consultation with an expert physician in Korea, the decision was made to proceed with transcatheter aortic valve replacement in a hybrid operating room with full surgical backup. We planned to deploy a 29-mm Medtronic Evolut FX self-expanding valve (SEV) through transfemoral approach low, 6- to 10-mm depth, to allow the outflow portion of the valve to seat precisely into the constrained STJ ring (Figure 2). The valve was implanted using the cusp-overlap view. Because the risk of valve embolization in this scenario is not low, we planned to partially deploy the valve, initially under rapid pacing, such that the valve was fully functional, but that we retained the ability to recapture it if there was concern about the positional stability of the valve. At that point, we would discontinue rapid pacing and wait 5 minutes to allow for full expansion of the nitinol frame at body temperature. This period was arbitrarily chosen based on our expectation that it would be sufficient to warm the nitinol frame to body temperature. We then would perform a gentle push-pull test to ensure the risk of valve migration was low before the irretrievable final release (Video 1). After valve deployment, pulse pressure immediately improved with trivial residual AI, and there was good coronary opacification with flow over the displaced native leaflets without the need for additional maneuvers to protect the coronaries. Postprocedural aortic valve area was calculated at 1.1 cm2 with peak and mean gradients of 26 and 11 mm Hg, respectively. The left ventricular ejection fraction was 60%. The patient did well but required a permanent pacemaker for increasing atrioventricular block and new left bundle branch block before discharge.
Figure 1.
Reconstructed computed tomography image on planning software demonstrating anatomy after comprehensive aortic root and valve repair, including the sinotubular junction ring.
Figure 2.
Illustration demonstrating the considerations and procedure plan. The partial annuloplasty ring used in the comprehensive aortic root and valve repair procedure may allow for expansion of the left ventricular outflow tract (LVOT) and annulus, unlike rigid prosthetic valve sewing ring, but this is unpredictable. We expected that the sinotubular junction (STJ) ring would serve as a rigid fixation point. The hourglass formation of the Evolut valve (Medtronic) was utilized for 2 landing zones for fixation of the valve: The STJ (yellow) and the annulus (red). We were required to implant the valve 6- to 10-mm deep, which should seat the outflow portion of the valve into the STJ ring. Implanting at this depth, placing the valve nearly annular (rather than supra-annular), should allow for some degree of sealing from the skirt at the annulus and in the LVOT.
Discussion
The CARVAR procedure has been performed in 397 patients in a single-surgeon series,1 but was abandoned amid concerns about ischemic complications, early valve failure, and excessive early mortality.2,3 TAVI has similar or improved perioperative survival compared with redo surgical aortic valve replacement.4 Although the frailty score and calculated risk score was low in this patient, CARVAR is not a procedure that is accounted for in these prediction models. Our major concerns for increased operative risk were the unknowns associated with approach to aortic valve replacement in these patients and the possibility of requiring an extensive root procedure. In addition, patient coronary grafts would increase the risk of resternotomy. For those reasons, we believed the patient would benefit more from a transcatheter rather than an open approach.
Generally, anchoring of TAVI valves occurs strictly at the annular level within the calcified native aortic valve or within the sewing ring of surgical prostheses and SEV frames are designed accordingly with high radial force at the inflow/annular portion. In off-label scenarios such as this, in which neither annular calcification nor a standard sewing ring are present, nontraditional anchoring points may be identified and utilized advantageously. Both the annulus and STJ act as fixed constraints that the hourglass shape of the Evolut valve can straddle. Kook and colleagues5 published a similar experience post-CARVAR, providing proof of concept for deployment deep into the left ventricular outflow tract. An interesting component of this case is the rigid STJ ring, which allowed for a secondary anchoring point. The concern with single-point fixation at the annular level in this patient was the lack of calcification and, therefore, higher risk of valve migration. The rigid STJ ring utilized by the CARVAR procedure provided a second fixation point that could be utilized with the SEV. The left ventricular outflow tract served as a point to prevent antegrade migration, whereas the STJ ring served as a point to prevent retrograde migration. This could not be achieved with the single-point fixation of a balloon expandable valve.5 Furthermore, we believed that the ability to partially deploy, recapture, and facilitate a push-pull test with the SEV was essential to completing the procedure as safely as possible. In addition, using a fully equipped hybrid operating room provided a safety net for rapid open conversion.
Preoperative planning for this case required extensive computed tomography analysis of the aortic root compared with typical TAVI for aortic stenosis to understand the dimensions of the STJ and annulus where contact with the SEV was anticipated (Figure 1). We were able to use, to our advantage, the design of the Evolut SEV to fit perfectly within the constrained root anatomy.
Conclusions
TAVI can be utilized by heart teams in complex, nontraditional but carefully selected cases; preoperative computed tomography imaging is essential; and safe, successful device deployment can be achieved with appropriate planning for contingencies.
Conflict of Interest Statement
Dr Wong has received consulting fees from Edwards LifeSciences and is a proctor for Artivion and Boston Scientific. All other authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
Footnotes
IRB Approval: Not required by our institution.
Informed Consent: Waived.
Supplementary Data
Conduct of the procedure under fluoroscopy demonstrating the considerations and steps for successful deployment. Video available at: https://www.jtcvs.org/article/S2666-2507(24)00248-7/fulltext.
Appendix E1
Table E1.
Preprocedural measurements for transcatheter aortic valve replacement planning
| Annular and aortic measurements | Diameter (mm) | Perimeter (mm) | Area (mm2) |
|---|---|---|---|
| Annulus | Min: 18.6 | 69.5 | 354.0 |
| Max: 23.9 | |||
| Mean: 21.3 | |||
| Left ventricular outflow tract | Min: 21.5 | 75.0 | 436.1 |
| Max: 27.0 | |||
| Mean: 24.2 | |||
| Sinotubular junction | Min: 24.9 | 84.3 | 559.5 |
| Max: 26.2 | |||
| Mean: 25.5 | |||
| Ascending aorta | Min: 34.4 | ||
| Max: 34.8 | |||
| Mean: 34.6 |
| Sinus of Valsalva and coronary measurements | |||
|---|---|---|---|
| Left | Right | Non coronary | |
| Sinus of Valsalva height (mm) | 18.2 | 29.0 | 26.9 |
| Sinus of Valsalva width (mm) | 35.4 | 30.8 | 32.9 |
| Coronary ostia height (mm) | 10.1 | 15.2 | |
| Access measurements | |
|---|---|
| Right femoral artery access: | |
| Common iliac | Min: 8.1, Max: 9.3, Mean: 8.7 (mm) |
| External iliac | Min: 8.2, Max: 8.6, Mean: 8.4 (mm) |
| Femoral | Min: 5.9, Max: 7.9, Mean: 6.9 (mm) |
| Views | ||
|---|---|---|
| LAO/RAO | Caudal/cranial | |
| Root view | LAO 1° | Caudal 0° |
| Cusp overlap | RAO 17° | Caudal 40° |
| Three cusp | LAO 5° | Caudal 26° |
| Near cusp overlap | RAO 8° | Caudal 35° |
| Other information | Annular angulation: 43° calculated at LAO 5°/caudal 26° | |
LAO, Left anterior oblique (LAO); RAO, right anterior oblique.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Conduct of the procedure under fluoroscopy demonstrating the considerations and steps for successful deployment. Video available at: https://www.jtcvs.org/article/S2666-2507(24)00248-7/fulltext.