Title:
Building Walls...The Right Way: Barricading a Pseudoaneurysm Closure Device with Valve-in-Valve TAVR
Introduction:
A 62-year-old African American female with a significant past medical history for aortic stenosis s/p surgical aortic valve replacement with a 21mm Magna Ease valve, mitral regurgitation s/p surgical mitral valve repair with 24mm Physio ring, ESRD on HD, permanent atrial fibrillation and heparin induced thrombocytopenia presented with decompensated heart failure secondary to severe bioprosthetic aortic valve stenosis.
Clinical Case:
Transthoracic echocardiogram revealed preserved left ventricular function (EF of 65%) with severe bioprosthetic aortic valve stenosis. Peak and mean trans-aortic valve gradient were elevated at 82 and 55mmHg, respectively with an acceleration time of 117ms and bioprosthetic aortic valve area of 0.53cm2. ECG-gated Cardiac CT revealed two pseudoaneurysms (PSA) of the ascending aorta, the larger of the two measuring at 28x20x14 mm and originating along the left coronary cusp posterior to the left coronary artery whereas the smaller PSA measured at 14x10x10 mm and originated between the left and non-coronary cusp. The maximal diameter of the larger PSA neck was measured to be 10mm. Cardiac CT revealed the both coronary ostium at the level of the bioprosthetic valve stent post, necessitating preprocedural planning with a virtual transcatheter heart valve (THV) implant. VTC to the left and right coronary artery using a 23mm self-expanding valve was measured at 5.1 and 4.8mm, respectively. The case was presented at a multidisciplinary team meeting and surgical intervention was considered prohibitive and thus a decision was made to proceed with percutaneous closure of the larger PSA and valve-in-valve (V-i-V) TAVR.
Via the left femoral artery, the PSA was engaged with a .035” hydrophilic glide wire, over which a 6Fr braided sheath was placed directly into the neck of the PSA. A 12 mm Amplatzer vascular plug (AVP) II device (St. Jude Medical, St. Paul, Minnesota) was then advanced into the PSA and its distal disc and body were unsheathed in the PSA. The proximal disc remained unsheathed within the ascending aorta. This was performed under CT fusion, and angiographic guidance. At this point, a 23 mm Evolut R system was advanced via retrograde aortic route and appropriately placed across the bioprosthetic aortic valve. At this point, the proximal disc of the AVP II valve was deployed with the outflow of the valve abutted against the proximal disc of the AVP II, anchoring it against the neck of the PSA. Following deployment and release of the Evolut 23 valve, the 12 mm AVP II device was released from the delivery catheter and landed anteriorly, circumventing the left coronary artery.
Discussion:
This case highlights the utility of synergistic deployment and anchoring of a pseudoaneurysm closure device via percutaneous transfemoral access with concomitant V-i-V TAVR, whilst avoiding coronary obstruction.