2020 Scientific Sessions

Title

Extreme Distortion of the Aorta

Introduction

We present a rare complex adult congenital case of extreme distortion of aorta with balloon coronary compression testing in a Centegra RV to pulmonary artery conduit being a contraindication for transcatheter valve implantation despite normal coronary flow. While, few studies have described distortion of the aorta in patients with transannular patch across the right ventricular outflow tract, this is an example in a conduit.

Clinical Case

A 26 year old male with history of Truncus arteriosus with multiple surgeries and pacemaker implantation complicated by endocarditis. Surgeries included truncal (aortic) valve prosthesis, pseudo aneurysm aortic repair, pacemaker and lead explantation, and four pulmonary conduit revisions with the most recent being a 24 mm pulmonary homograft. Follow up echocardiography showed increased stenosis. Palliative balloon angioplasty as a bridge to valve implantation was unsuccessful. Hemodynamic evaluation confirmed a 55 mmhg gradient and 2/3 systemic right ventricular pressures. Angiography visualized significant narrowing to 10 to 11 mm. In preparation for transcatheter valve implantation and pre stenting coronary balloon compression testing with a 22 noncompliant balloon showed significant severe distortion of the aorta in multiple angiographic views. Intracardiac imaging displayed increase aortic valve regurgitation. Decision to pre stent and subsequent placement of transcatheter valve was abandoned in favor of repeat surgical conduit revision. Alternatively, the narrowing would not be relieved by distal conduit or bilateral pulmonary artery valve implantation.

Discussion:

The case is an example of extreme distortion of the aorta that should be considered a contraindication for either stent or transcatheter valve implantation regardless of coronary flow.