Abstract
A 75-year-old man with severe aortic stenosis, severe chronic obstructive pulmonary disease, NYHA class III heart failure and a large abdominal aortic aneurysm underwent concurrent transfemoral transcatheter aortic valve replacement (TF-TAVR) and endovascular aneurysm repair (EVAR). An Edwards Sapien device was implanted with resolution of hemodynamics. EVAR was performed using an Endurant bifurcated stent graft system.
We describe the procedure technique, periprocedural management and one year outcome. To the authors’ best knowledge, this is the first case of simultaneous TF-TAVR and EVAR published in North America.
1
Introduction
Due to exclusion from the PARTNER trial and the risk of vascular complications some transcatheter aortic valve replacement (TAVR) programs have chosen to avoid transfemoral (TF) TAVR in patients with abdominal aortic aneurysm (AAA) .
We report a case of severe aortic stenosis (AS) in a patient with a concurrent large AAA repaired simultaneously with TF-TAVR and endovascular aneurysm repair (EVAR).
2
Case presentation
A 75-year-old man with severe AS, chronic obstructive pulmonary disease (COPD) on supplemental oxygen therapy and chronic kidney disease, referred with NYHA Class III heart failure symptoms and exertional angina to our valve clinic for evaluation of options for aortic valve replacement.
Transesophageal echocardiography revealed normal left ventricular function, severe tri-leaflet calcific disease, and aortic valve area of 0.6 cm 2 consistent with critical AS ( Fig. 1 ). Mean gradient was 48 mmHg, peak velocity of 5.3 m/s, annulus diameter of 23 mm and sinotubular junction dimension of 30 mm. Spirometry revealed severe COPD with FEV1 of 0.88 l (31% of predicted); FEV1 to FVC ratio was 23% of predicted. CT angiography revealed an (5.1 cm) infra-renal AAA centered near the inferior mesenteric artery origin, terminating at the aortic bifurcation.
He was deemed not to be a surgical candidate. The valve team comprising interventional cardiology, cardiac and vascular surgery, cardiovascular imaging and cardiac anesthesia recommended TF-TAVR and EVAR.
Our multidisciplinary team offered three scenarios. Scenario A: Perform staged TF-TAVR and TF-EVAR, with the attendant risks of having two separate proximate operative procedures. Scenario B: Perform TF-EVAR after but at the same setting of TAVR if the device tracked easily through the AAA, and if TF-TAVR was performed without major adverse incident. Scenario C: If the device failed safe transit through the AAA, TF-EVAR would be performed first and TF-TAVR would be performed through the endograft if TF-EVAR was performed without major adverse incident. The patient provided informed consent for all three scenarios. The patient underwent simultaneous TF-TAVR and TF-EVAR per scenario B.
Resolution of AS hemodynamics was confirmed by simultaneous left ventricular and central aortic pressure measurements. A 26 mm Edwards Sapien TAVR device and a Medtronic 32 × 16 × 145 mm main body Endurant bifurcated EVAR stent graft system were used. Completion angiography demonstrated patent endograft without evidence of an endovascular leak. Extubation was successful immediately post procedure. Post procedure chest X-ray revealed good positioning of the TAVR and EVAR devices ( Fig. 2 ). The patient’s post-operative course was uneventful, and he was discharged in stable condition after 72 h.
2
Case presentation
A 75-year-old man with severe AS, chronic obstructive pulmonary disease (COPD) on supplemental oxygen therapy and chronic kidney disease, referred with NYHA Class III heart failure symptoms and exertional angina to our valve clinic for evaluation of options for aortic valve replacement.
Transesophageal echocardiography revealed normal left ventricular function, severe tri-leaflet calcific disease, and aortic valve area of 0.6 cm 2 consistent with critical AS ( Fig. 1 ). Mean gradient was 48 mmHg, peak velocity of 5.3 m/s, annulus diameter of 23 mm and sinotubular junction dimension of 30 mm. Spirometry revealed severe COPD with FEV1 of 0.88 l (31% of predicted); FEV1 to FVC ratio was 23% of predicted. CT angiography revealed an (5.1 cm) infra-renal AAA centered near the inferior mesenteric artery origin, terminating at the aortic bifurcation.
