ECMO Supported Valve-in-Valve Transcatheter Aortic Valve Replacement
Presenter
Konstantinos Voudris, M.D., Ph.D., FSCAI, Minneapolis Heart Institute - Abbott Northwestern Hospital, Minneapolis , MN
Konstantinos Voudris, M.D., Ph.D., FSCAI1, Michael R. Mooney, M.D., FSCAI2, Paul Sorajja, M.D., FSCAI2, Marcus R Burns, DNP3, Caitlin Kronenwetter2, Mario Goessl, M.D., FSCAI3, Anil K. Poulose, M.D., FSCAI4 and Ivan J. Chavez, M.D., FSCAI2, (1)Minneapolis Heart Institute - Abbott Northwestern Hospital, Minneapolis , MN, (2)Minneapolis Heart Institute® - Abbott Northwestern Hospital, Minneapolis, MN, (3)Abbott Northwestern Hospital, Minneapolis, MN, (4)Minneapolis Cardiology Associates, Minneapolis, MN
Title
ECMO Supported Valve-in-Valve Transcatheter Aortic Valve Replacement
Introduction
Patients with aortic stenosis and cardiogenic shock are an extremely high-risk population with a dismal prognosis. We present a case of cardiogenic shock secondary to transcatheter aortic valve replacement (TAVR) valve thrombosis necessitating peripheral Veno-Arterial ExtraCorporeal Membrane Oxygenation (VA-ECMO) and valve-in-valve TAVR.
Clinical Case
A 74-year-old man with history of pulmonary embolism (on Rivaroxaban) and TAVR CoreValve Evolut Pro 29mm in 2019 (Medtronic, Minneapolis, MN) presented to an outside hospital with shortness of breath, orthopnea and weight gain. He was transferred to our institution with cardiogenic shock (SCAI stage D) on Norepinephrine, Vasopressin, Dobutamine and Dopamine. Initial ECHO showed severely decreased left ventricular function (EF 10-20%), limited leaflet mobility with high echogenicity of the aortic valve (mean gradient of 46mmHg, prosthetic orifice area 0.91 cm2 and DVI 0.17) and mild paravalvular regurgitation. Bedside right heart catheterization confirmed high filling pressures (PCWP 40mmHg and CI 1.9). CVVH was initiated for fluid removal. After multidisciplinary heart team discussion, decision was made to proceed with peripheral VA-ECMO cannulation and valve-in-valve TAVR. Prior post-TAVR CTA was used for valve sizing and coronary height evaluation. Left common femoral artery was cannulated using a 15-Fr single stage cannula and a 25-Fr multistage venous drainage cannula was placed in the right common femoral vein. VA-ECMO was initiated with flows between 2.5 and 3L. Subsequently the patient was intubated and invasive gradients were obtained (42.3mmHg) confirming the presence of severe aortic stenosis. A26mm Sapien S3 Ultra valve (Edwards Lifesciences, Irvine, CA) was advanced through the right femoral artery and deployed under rapid ventricular pacing. After deployment, invasive gradient was reduced to 10mmHg and mild paravalvular regurgitation remained unchanged. ECMO flow was reduced to 0.5 L with stable systolic blood pressure and left ventricular end diastolic pressure (40mmHg). At that point decision was made to decannulate the patient in the lab. Two Perclose Proglide (Abbott, Chicago, IL) were deployed in the left common femoral artery and a “figure of 8” stich in the right common femoral vein. Patient was transferred to the cardiac intensive care unit intubated on decreased doses of inotropic support. He was extubated and weaned off pressures on post operative day 1 with good urine output. Transthoracic echocardiogram on post operative day 2 showed improved systolic function (EF 30%), valve gradient of 16mmHg across the aortic valve and mild-moderate paravalvular regurgitation. Repeat right heart catheterization on day 2 showed improved pressures (RA 9mmHg, PA 61/20/34mmHg, PCWP 24mmHg, CI 3.3). He was discharged home on post operative day 12.
Discussion
This case demonstrates the feasibility of VA-ECMO supported valve-in-valve TAVR in select patients. Patients on cardiogenic shock are at an increased risk for 30-day and 1-year mortality and are traditionally not considered for TAVR given limitations in pre-procedural planning and procedural aspects. In our case peripheral VA-ECMO provided us the necessary hemodynamic support during valve deployment and rapid pacing in the setting of severely reduced systolic function and elevated left ventricular end diastolic pressure.