1

Case presentation

A 51-year-old male with systemic lupus and severe renal failure was admitted to our center for an episode of acute heart failure.

He had undergone surgical replacement of the aortic root with an homograft at the age of 37 because of a severe dilatation of the ascending aorta with aortic valve regurgitation (AR). Ten years later, he developed severe left ventricular dysfunction and dilatation with progressively worsening pulmonary hypertension. Despite optimal medical management he evolved into a class IV heart failure.

At the time of presentation trans-thoracic echocardiography revealed a left ventricular ejection fraction around 20%. Mesaurements of the homograft at the level of the anulus, sino-tubular junction and aortic root were respectively 25, 39 and 37 mm, while trans-aortic Doppler showed peak and mean gradients of 20 and 10 mm Hg, with a velocity of 2.2 m/s. Trans-esophageal ecocardiography confirmed the dimension of the left ventricular outflow. At angio-CT scan the virtual basal ring was elliptic with major and minor axes measuring 28 and 24 mm, respectively, and the ascending aorta was severely dilated with a maximum transverse diameter of 53 mm.

Cardiac catheterization demonstrated a cardiac output of 2.58 l/min (cardiac index: 1.5 l/min/m ² ), PAP: 85/31/55, PVR: 5.86 HRU) and angiography revealed normal coronary arteries and mild AR, likely underestimated because of the low cardiac output and inotropic support.

Despite the young age, cardiac transplantation was excluded due to the chronic immunosuppressive state, irreversible severe pulmonary hypertension and severe renal insufficiency (eGFR: 28 ml/min/m ² ). After thorough discussion within the Heart Team, the implantation of a HeartMate II left ventricular assistance device (LVAD) was decided as a destination therapy.

2

Intervention

Based on our previous experience the possibility of a CoreValve implantation after activation of the LVAD was considered in case of acute worsening of the AR with hemodynamic impairment. This hybrid therapeutic option was preferred to the concomitant surgical valve repair to avoid opening of the homograft that appeared severely degenerated and calcified as shown in Fig. 1 a and b . A bail-out TAVI implantation with a Portable x-ray equipment was organized in the operating room. Indeed, immediately after LV assistance, CO rapidly dropped below 2.0 l/min and the intra-operatory trans-esophageal echocardiography demonstrated the worsening of the AR due to the retrograde flow created by the LVAD ( Fig. 2 a,b ). A 31-mm CoreValve was then implanted by the right femoral route. Due to the low quality of the images produced by the Portable x-rays equipment and in order to reduce the dose of contrast media, a needle was positioned on the opened chest at the level of the aortic annulus as a landmark for valve deployment ( Fig. 3 a ). After the release of the aortic valve, the CO raised to 3.4 l/min, although important peri-valvular leak was still evident ( Fig. 3 b). Subsequent post-dilatations of the CoreValve with semi-compliant balloons (28 and 30 mm) reduced the para-valvular leak significantly, and this resulted in immediate improvements of the CO to 4.3 and 5.1 l/min respectively ( Fig. 4 a–c ).

transversal (a) and longitudinal (b) views of the CT scan of the ascendant aorta showing a severely calcified and dilated vessel (arrow).

Stay updated, free articles. Join our Telegram channel

Join