Abstract
A 67-year-old man with a dilated cardiomyopathy and severe aortic regurgitation (AR) secondary to a traumatic cusp lesion was referred to our institution because of progressive worsening of dyspnea. After formal discussion in the heart team, the patient was scheduled for TAVI (transcatheter aortic valve implantation). The pre procedural computed tomography scan revealed a minimum amount of calcium on the aortic valve and low position of coronary ostia. The TAVI procedure was performed with the implantation of a fully retrievable and repositionable aortic valve prosthesis (Direct Flow 29 mm, Direct Flow Medical, Santa Rosa, California) with an excellent result and no paravalvular leak. The TAVI devices designed for the treatment of calcific aortic stenosis have numerous limitations for the treatment of pure AR such as the risk of residual AR, the lack of repositionability and retrievability, and the need for valve- in-valve implantation. We believe that treatment of selected cases of pure AR with the Direct Flow valve is feasible and takes advantage of the retrievability of the prosthesis.
1
Clinical history
A 67-year-old male with dilated cardiomyopathy and severe aortic regurgitation (AR) was admitted because of worsening dyspnea. He had a previous history of chronic kidney disease, left anterior descending (LAD) artery stent implantation for an acute myocardial infarction with later evidence of in-stent restenosis and an aneurysm of the left ventricular (LV) apex. He thus underwent coronary artery bypass grafting (with a left internal mammary artery graft to LAD and saphenous vein graft to ramus) and LV restoration. He also underwent implantation of a CRT-D because of severe LV dysfunction and left bundle branch block.
On admission, transesophageal echocardiography (TEE) showed severe aortic regurgitation due to undefined traumatic damage of the left coronary cusp with a piece of floating tissue attached to the ventricular aspect of the valve ( Fig. 1 ); severe LV dilatation (end diastolic diameter 76 mm) and dysfunction (ejection fraction 35%) and moderate functional mitral regurgitation. The precise etiology of the coronary cusp fracture was unknown, although an iatrogenic damage (at the time of previous surgery and/or catheterization) was strongly suspected.
The logistic EuroSCORE was 9.7% and the STS Predicted Risk of Mortality (PROM) score was 8.3%. After formal heart team discussion, agreement was reached on attempting transcatheter aortic valve implantation (TAVI). Computed tomography showed a large aortic annulus (24 × 29 mm, perimeter 88 mm) and reduced distance between both coronary ostia and the virtual basal ring (height of left and right coronary ostia respectively 13 and 12 mm). Bypass grafts resulted to be patent. A 29 mm Direct Flow prosthesis (Direct Flow Medical, Santa Rosa, California) was implanted without predilation. The valve was implanted in a lower than usual position to avoid coronary obstruction.
Before the polymer exchange to permanently fixate and release the valve, we did a push test that confirmed the optimal stability of the valve. No paravalvular leak or interference with coronary ostia was noted at aortogram ( Fig. 2 ) and TEE. The post-procedural clinical course was uneventful. At two-month follow-up, the patient was asymptomatic; a transthoracic echocardiography confirmed the correct function of the valve with no paravalvular leaks ( Fig. 1 e and f).
