Abstract
Aortic stenosis is a prevalent disease with poor prognosis if left untreated. Transcatheter aortic valve implantation (TAVI) is an emerging treatment for patients at high risk for surgery. We describe a patient withno suitable peripheral access due to peripheral vascular disease (PVD) for TAVI. Direct aortic approachvia an 18-Fr sheath inserted into the ascending aorta was successfully performed with a 29-mm CoreValve implanted. Direct aortic approach is feasible for TAVI in patients with severe PVD without good peripheral access.
1
Introduction
Transcatheter aortic valve implantation (TAVI) has emerged as a viable option for patients who are high risk or rejected for conventional aortic valve replacement. Transfemoral approach is the most common access route for TAVI and associated with most favourable clinical outcomes. However, in patients with no suitable femoral access, due to either severe peripheral vascular disease or small vessel calibre, direct aortic approach utilizing CoreValve and transapical approach with Edwards SAPIEN valves are the feasible approach. We report our experience in direct aortic approach for TAVI in a patient with no suitable peripheral access.
2
Case description
An 84-year-old gentleman was referred to our hospital for severe symptomatic aortic stenosis (AS). He was physically active and walked unaided. Background history included hypertension, hypercholesterolemia, 7-cm infra-renal abdominal aortic aneurysm ( Fig. 1 ), chronic kidney disease, and coronary artery disease with 60% stenosis at the proximal left anterior descending artery and 95% stenosis in an intermediate branch. He suffered increasing dyspnoea (NYHA Class II–III) in the last few months. Transthoracic echocardiogram showed a heavily calcified aortic valve with a mean gradient of 53 mmHg, aortic valve area of 0.68 cm 2 , mildly impaired left ventricular function, and moderate mitral regurgitation.
Multidisciplinary meeting concluded that he was too high risk forconventional aortic valve replacement (AVR) with concomitant coronary artery bypass graft [EuroSCORE 31.2% and Society of Thoracic Surgeons score 15.6% for mortality). Thus, we decided to perform TAVI utilizing CoreValve via direct aortic approach.
Under general anaesthesia, a 4-Fr balloon-tipped pacing wire was placed at the right ventricular (RV) apex via the right internal jugular vein. A horizontal incision, approximately 6–8 cm, was made at the right second intercostal space with dissection of the underlying tissue to expose the ascending aorta . The right lung was retracted, and a self-retaining retractor was placed to allow optimal exposure of the ascending aorta. Under direct visualization together with fluoroscopic guidance, optimal position for aortic cannulation was chosen. The ascending aorta was then cannulated directly with an 18-Fr Cook sheath after purse-string sutures were pre-laid ( Fig. 2 ). The aortic valve was crossed using a straight 0.035-in. wire with aortic valvuloplasty performed using a 22-mm Nucleus balloon under rapid RV pacing. A 29-mm CoreValve was implanted as the annulus size was 25mm on pre-TAVI computed tomography scan. The ascending aorta was decannulated with purse-string sutures, and final aortogram demonstrated good haemostasis at the sheath entry site and mild paravalvular aortic regurgitation. The patient was discharged on Day 8 with good recovery.
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