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Fig 4. (A) The postoperative computed tomographic scan confirmed a good configuration and no apical stenosis of the apicoaortic valved conduit bypass and (B) indicated that there were no problems at the distal site of the graft.
© 2013 by The Society of Thoracic Surgeons Published by Elsevier Inc
In conclusion, we successfully repaired, using AAVCB, a severe, progressing aortic graft stenosis resulting from previous serial treatments by TEVAR originally performed for treating AAD.
We are indebted to Dr Clifford Kolba (DO, DEd) and Dr Edward F. Barroga (PhD) of the Department of International Medical Communications of Tokyo Medical University for their editorial review of the English manuscript.
References 1. Carrel A. VIII. On the experimental surgery of the thoracic aorta and heart. Ann Surg 1910;52:83–90. 2. Cooley DA, Norman JC, Mullins CE, Grace R. Left ventricle to abdominal aorta conduit for relief of aortic stenosis. Cardiovasc Dis 1975;2:376 – 83. 3. Cooley DA, Lopez RM, Absi TS. Apicoaortic conduit for left ventricular outflow tract obstruction: revisited. Ann Thorac Surg 2000;69:1511– 4. 4. Pirotte M, Lacroix V, Astrarci P, et al. Unsuccessful treatment of a collapsed thoracic stent graft by Palmaz stent. Ann Vasc Surg 2010;24:1137.e13–9.
Transapical Aortic Valve-in-Valvein-Valve Implantation as a Procedural Rescue Option Joerg Kempfert, MD, Felix Girrbach, MD, Martin Haensig, MD, Sreekumar Subramanian, MD, David Michael Holzhey, MD, and Friedrich Wilhelm Mohr, MD, PhD Department of Cardiac Surgery, Kerkhoff Clinic, Bad Nauheim, Germany; Department of Cardiac Surgery, Heart Center of the University of Leipzig, Leipzig, Germany; and Department of Surgery, University of Arizona Medical Center, Tucson, Arizona 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2012.05.063
FEATURE ARTICLES
ported by Cooley and colleagues [2] in 1975, originally as a radical surgical treatment for patients with LV outflow stenosis. Later on, the method was reevaluated by Cooley and colleagues and reported in 2000 [3], as they made the procedure simpler by taking the distal anastomosis to the descending aorta, using a transthoracic approach. In the present case, we performed the AAVCB to treat critical, progressing aortic graft stenosis, which had occurred due to complications from previous surgical treatments. These complications consisted of malformation of the repeated TEVAR procedures, previously performed for the treatment of the patient’s AAD, in addition to thrombus formation in the TEVAR and EVAR grafts. There have not been any reports similar to ours in the literature. We consider the interesting mechanism of progressing aortic graft stenosis in our patient to be as follows. The first event in the process of serial deterioration of congestive heart failure was thought to be aortic graft stenosis due to the malformation of the ascending TEVAR graft. Then physical obstruction of the aorta caused deterioration of the cardiac function, which simultaneously resulted in thrombus formation due to low blood flow in the TEVAR and EVAR grafts. In addition, systemic infection resulting from the original sternal wound infection likely caused abnormalities in the coagulation and fibrinolytic systems, which possibly increased thrombus formation in the TEVAR and EVAR grafts. Subsequently, aortic graft stenosis and low cardiac output progressed gradually, along with this thrombus formation. Pirotte and colleagues [4] had previously reported a similar case of thrombus formation originating from a Palmaz stent that was deployed in a proximally collapsed TEVAR graft; this case was treated successfully with open surgery. These authors also reviewed 32 previously reported cases according to initial incoming diagnosis and treatment. However, there was no case of AAD in their review, which was similar to ours.
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Device malposition and dysfunction with resultant severe aortic insufficiency are known complications of transcatheter aortic valve implantation (TAVI). Fortunately, these complications can often be successfully treated with a transcatheter valve-in-valve (VinV) implantation. However, prosthetic leaflet dysfunction or immobility from the VinV configuration can lead to severe central aortic insufficiency. We report the first known case of implantation of a third SAPIEN prosthesis (Edwards Lifesciences, Irvine, CA) during TAVI as a valuable bailout strategy to deal with severe aortic insufficiency after VinV implantation. (Ann Thorac Surg 2013;95:325– 8) © 2013 by The Society of Thoracic Surgeons
T
he valve-in-valve (VinV) technique is an excellent “bail-out” option in case of transcatheter aortic valve malposition leading to severe paravalvular or central aortic insufficiency (AI) [1]. The objective of this report is to describe a novel strategy, if a second SAPIEN prosthesis is unsuccessful.
FEATURE ARTICLES
A frail 61-year-old man with severe aortic stenosis (maximum and mean pressure gradient [Pmax/Pmean] of 81/45 mm Hg, aortic valve area 0.4 cm2) was admitted with New York Heart Association class IV. Major comorbidities included coronary 3-vessel disease status post aortocoronary bypass (SYNTAX score 36.5), stage IV chronic renal insufficiency requiring permanent hemodialysis, pulmonary hypertension, insulin-dependent diabetes, a history of a duodenal ulcer with severe bleeding 6 months prior to surgery, and history of factor V leiden thrombophilia. The patient=s logistic European system for cardiac operative risk evaluation and the Society of Thoracic Surgeons risk score were 34.0% and 6.2%, respectively. Given the high risk of conventional surgery, transapical aortic valve implantation was considered during the Heart Team conference to be the patient=s best option. The aortic annulus was 24 mm and preoperative left ventricular ejection fraction was 28%. Accepted for publication May 4, 2012. Address correspondence to Dr Kempfert, Department of Cardiac Surgery, Kerckhoff Clinic, Benekestrasse 2-8, 61231 Bad Nauheim, Germany; e-mail:
[email protected].
Fig 1. Transapical aortic valve implantation: SAPIEN 26. (A) Position of the first transcatheter valve. (B) Severe paravalvular leak due to slightly high positioning (long-axis view).
Ann Thorac Surg 2013;95:325– 8
Transapical aortic valve implantation was performed as previously described in detail [2]. After standard crimping, the valve (26-mm SAPIEN XT prosthesis, Edwards Lifesciences Corporation, Irvine, CA), mounted on the Ascendra 2 delivery system (Edwards Lifesciences), was implanted under a second phase of rapid ventricular pacing (Fig 1A). Because valve position was slightly high, a significant paravalvular leak was present (Fig 1B). The severity of the paravalvular insufficiency persisted after post dilatation with no improvement and the implantation of a second valve within the first one was then considered. Positioning was performed using the radiopaque stent of the first valve as a landmark. The implantation of the VinV was carried out in a pronounced controlled, stepwise manner with the second prosthesis in a slightly lower position (Fig 2A). Transesophageal echocardiographic images revealed resolution of the paravalvular leak, but a severe central leak was now present (Fig 2B). Whether the incompetence was due to leaflet dysfunction or interference between both valve leaflets remained unclear. Thus, the only options were to implant a third transcatheter valve or convert to median sternotomy. By intention, a 23-mm SAPIEN valve was chosen and implanted successfully within both SAPIEN valves (Fig 3). Echocardiographic and angiographic assessment revealed no aortic incompetence or paravalvular leak (Fig 3B). The total procedural time was 2 hours 5 minutes, with a total radiation time of 15 minutes and 135 mL contrast dye application. The early postoperative course was uneventful. The patient was extubated within 2 hours and transferred to the normal ward within 24 hours. Postoperative echocardiography revealed good aortic valve function, without paravalvular leakage and transaortic gradients of Pmax/ Pmean 24.5/16.2 mm Hg. The patient was discharged to a rehabilitation facility on postoperative day 18. Three months after surgery, the patient remains asymptomatic with consistently acceptable transvalvular gradients (Pmax/Pmean 22 of 13 mm Hg).
Comment Transcatheter aortic valve implantation is now commonplace in Europe for high-risk patients with aortic valve
Abbreviations and Acronyms AI ⫽ aortic insufficiency ES ⫽ EuroSCORE EuroSCORE ⫽ European system for cardiac operative risk evaluation score NYHA ⫽ New York Heart Association Pmax ⫽ peak pressure gradient Pmean ⫽ mean pressure gradient STS ⫽ Society of Thoracic Surgeons SYNTAX ⫽ SYNergy between PCI with TAXUS and Cardiac Surgery TA-AVI ⫽ transapical aortic valve implantation TAVI ⫽ transcatheter aortic valve implantation TEE ⫽ transesophageal echocardiography VinV ⫽ valve-in-valve
disease, and it has ushered in a new era in aortic valve surgery [3]. However, if severe aortic insufficiency (AI) persists despite post dilatation, a clear strategy is critical to optimize outcomes. The first option for the treatment of significant paravalvular leaks after TAVI is balloon post dilatation. Post dilatation should be performed using a slightly larger balloon, usually filled with 1 extra milliliter of fluid. However, the use of oversized balloons is limited by the possibility of inducing incomplete coaptation of the valve leaflets, eventually leading to a significant central leak. The VinV strategy represents the second option. Initially, VinV implantation has only been used in case of central leaks due to either leaflet dysfunction or borderline low positioning. However, in case of paravalvular leak the VinV technique can also be considered if either the initial valve prosthesis appears to be too small or insufficient, overlapping of the “covered” part of the SAPIEN stent with the aortic annulus has to be assumed due to malpositioning [1]. In the setting of a “too small valve” a second valve will result in both a higher radial force and an increase in the amount of the material within the native valve. As the
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SAPIEN valve has a stent profile of approximately 1 mm, the annulus will be “shrunk down” by 2 mm. Thus, the second valve with the same size will then overextend the first one and can be positioned exactly within the first one. In the second scenario where insufficient covering is suspected due to suboptimal valve positioning (either too high or too low) the implantation of a VinV aims to increase the “covered zone” within the aortic annulus. Thus, the second valve needs to be positioned higher or lower to correct initial misplacement. Usually, the second prosthesis will fully cover the leaflets of the first one. However, as we have experienced in this case, if the second valve is positioned significantly lower (or higher) full covering of the first SAPIEN leaflets might not occur. Subsequently, we observed a phenomenon where the still active leaflets of the first valve interfered with the diastolic flow pattern of the second valve, resulting in a severe central leak. Thus, care should be taken not to “overcorrect” initial valve malposition. If persistent or worsening AI is present after VinV implantation, serious consideration should be given to conversion to sternotomy. However, if dysfunction or immobility of leaflets is suspected, freeing a “stuck” leaflet can be attempted by moving the pigtail catheter in the aortic root. A truly immobile leaflet is a rare complication that might be associated with the crimping process. In this case, it seemed that the leaflets of the first SAPIEN valve were still “active” above the leaflets of the second SAPIEN valve, blocking the free diastolic flow onto the leaflets of the lower valve. The second valve might not have caught the leaflets of the first valve resulting in severe central leak due to an impaired diastolic flow pattern. Discrimination of true dysfunctional versus “stuck” leaflets due to insufficient diastolic flow because of a borderline low SAPIEN position with the upper leaflets still active is often not feasible. However, in both failure modes, conversion to sternotomy, operative removal of both transcatheter valves, and surgical aortic valve replacement should be considered. When required, conversion is best performed in a fully equipped hybrid suite by a specialized team. The present report describes implantation of a third transcatheter valve as a last bailout option for persistent
Fig 2. Valve-in-valve aortic: SAPIEN 26 in SAPIEN 26. (A) Valve-in-valve in a slightly lower position. (B) Angiographic result with severe central leak due to dysfunction or interference.
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CASE REPORT MORSOLINI ET AL AORTIC VALVE OPERATION AFTER LUNG TRANSPLANT
Ann Thorac Surg 2013;95:328 –30
Fig 3. Valve-in-valve as a valuable “bail-out” technique: SAPIEN 23 in SAPIEN 26. (A) Third transcatheter valve in a central position. (B) Final angiographic result.
AI after transcatheter VinV implantation. Because this strategy resolved AI, was not associated with adverse in-hospital complications, and resulted in acceptable gradients at short-term follow-up, we believe this is a feasible alternative to sternotomy for unsuccessful TAVI. Despite the intraoperative challenges, this maneuver led to an excellent functional result. The simple straight tubular stent design of the SAPIEN prosthesis may be the ideal design for such a “bail-out.”
References FEATURE ARTICLES
1. Kempfert J, Rastan AJ, Schuler G, et al. A second prosthesis as a procedural rescue option in trans-apical aortic valve implantation. Eur J Cardiothorac Surg 2010;40:56 – 60. 2. Walther T, Dewey T, Borger MA, et al. Transapical aortic valve implantation: step by step. Ann Thorac Surg 2009;87: 276 – 83. 3. Smith CR, Leon MB, Mack MJ, et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med 2011;364:2187–98.
Aortic Valve Replacement Performed Twice Through Ministernotomy 15 Years After Lung Transplantation Marco Morsolini, MD, Giuseppe Zattera, MD, Federica Meloni, MD, and Andrea Maria D’Armini, MD Department of Surgery, Division of Cardiac Surgery, and Division of Respiratory Diseases, University of Pavia School of Medicine, Foundation “I.R.C.C.S. San Matteo” Hospital, Pavia, Italy
After transplantation, steroids and calcineurin inhibitors together with end-stage renal failure may lead to associated cardiovascular diseases, particularly in long-term survivors. We present a case of aortic valve replacement 15 years after lung transplantation, followed by reoperaAccepted for publication June 8, 2012. Address correspondence to Dr Morsolini, Division of Cardiac Surgery, Foundation “I.R.C.C.S. San Matteo” Hospital, Piazzale Golgi, 2–27100 – Pavia, Italy; e-mail:
[email protected].
© 2013 by The Society of Thoracic Surgeons Published by Elsevier Inc
tive valve replacement for late infective endocarditis. Lung compliance and gas exchange were excellent during recovery. Despite adequate prophylaxis, immunosuppression and hemodialysis likely contributed to repeated episodes of sepsis, which caused detachment of the first aortic prosthesis. Despite the high mortality of prosthetic valve endocarditis, the postoperative course was uneventful and the patient is doing well at 24-month follow-up. (Ann Thorac Surg 2013;95:328 –30) © 2013 by The Society of Thoracic Surgeons
I
mproved patient selection, surgical technique, postoperative management, and immunosuppressive protocols over the past decades have resulted in remarkable improvement in outcomes of thoracic transplantation and, consequently, in increased numbers of elderly patients among transplant survivors in whom cardiovascular diseases may develop, particularly after the onset of chronic renal failure [1]. As short-term and long-term survival rates after lung transplantation continue to improve and as more lung transplantations are performed each year, a multitude of medical complications such as hypertension, hyperlipidemia, and diabetes are frequently observed [2]. Although cardiac operations in patients who have undergone heart transplantation are frequently supported in the literature, such operations following lung transplantation are rarely reported [3–5]. In 1994, a 22-year-old man diagnosed with ventricular septal defect at the age of 5 years underwent double-lung transplantation and ventricular septal defect repair through a clamshell incision. The postoperative course was uncomplicated and he was given standard immunosuppression including cyclosporine, azathioprine, and prednisone. After transplantation, the patient returned to a normal life, showing a considerable improvement in exercise tolerance without oxygen supply. Since 2007 he has required chronic dialysis. He never experienced any episode of lung rejection, and lung function was stable at 95% of his best posttransplantation value. Because of the onset of dyspnea with temporary relief immediately after dialysis, in 2009 a transthoracic echo0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2012.06.026
