Transcatheter aortic valve replacement (TAVR) has emerged as a viable treatment option for patients with symptomatic aortic stenosis across all surgical risk groups. Although the need for alternative access to transfemoral access is becoming less frequent due to better device profiles, there is a continued need for such options. Common approaches used today include subclavian, carotid, caval, aortic, or apical. However, the transseptal approach has not been described with the current S3 delivery system. We present, to our knowledge, the first reported case of a transseptal TAVR using the standard delivery system and under monitored anesthesia care (MAC). This case demonstrates that advances in maneuverability and device profile make transseptal delivery of the S3 valve a safe and effective approach in some patients with no other peripheral arterial access.
Highlights
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The transseptal approach for transcatheter aortic valve replacement (TAVR) can be considered in patients with no other peripheral arterial access.
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Transseptal TAVR can be achieved using the standard S3 Commander delivery system.
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Monitored anesthesia care can be utilized in patients requiring transseptal TAVR for whom mechanical ventilation poses an increased risk.
Case Description
A 75-year-old woman was evaluated at our tertiary care center for heart failure symptoms following decades of cardiac interventions. Her medical history was notable for coronary artery disease with bypass graft surgery 22 years prior, ischemic cardiomyopathy with a cardiac resynchronization therapy defibrillator, carotid stenosis with right carotid endarterectomy 12 years prior, and peripheral arterial disease (PAD) with aortoiliac bifurcation stenting. Her history also included hypertension, hyperlipidemia, idiopathic pulmonary fibrosis, and chronic kidney disease.
Laboratory testing showed mild anemia (hemoglobin 10.9 g/dL) and elevated creatinine (1.70 mg/dL). Electrocardiography indicated atrial fibrillation with biventricular pacing. Left heart catheterization revealed 60% right coronary mid stenosis and 80% left main coronary ostial stenosis with patent left internal mammary artery to left anterior descending artery and saphenous vein to obtuse marginal grafts. Subclavian stenosis was also observed with <20 mm gradient at rest. Transthoracic echocardiography demonstrated a reduced left ventricular ejection fraction of 46% and a reduced stroke volume index of 23 mL/m 2 . It also showed moderate aortic insufficiency and severe aortic valve stenosis, with valve area measuring 0.52 cm 2 and peak and mean pressure gradients of 43 and 26 mmHg, respectively. In addition, there was moderate mitral regurgitation and mild mitral stenosis, as well as moderate tricuspid regurgitation and moderate right ventricular dysfunction. Computed tomography angiography illustrated severe PAD with calcification of the femoral, axillary, and carotid arteries as well as the abdominal aorta.
Novel Technique
The patient was deemed high-risk for surgery and was a candidate for TAVR. However, her PAD precluded valve delivery through the femoral, axillary, or carotid arteries, and severe calcification precluded direct aortic access. Furthermore, a transcaval approach was not feasible with limited calcium-free aortic access and a lack of bailout strategy in the event of an intraabdominal bleed due to her history of aortic surgery and extensive calcification of the abdominal aorta. A transseptal approach was thus elected ( Figure 1 ). General anesthesia was not recommended due to the patient’s idiopathic pulmonary fibrosis. MAC was administered, and intracardiac echocardiography (ICE) was performed in lieu of transesophageal echocardiography.
Preprocedural antibiotic was administered intravenously, and sterile technique was used throughout the case. All vascular access was obtained using micropuncture technique. An 8-Fr sheath was placed in the right common femoral vein and was ultimately exchanged for a 14-Fr eSheath. Through the right common femoral artery, a 5-Fr straight flush catheter was used to mark the noncoronary cusp of the aortic valve. A 5/6-Fr slender sheath was placed in the right radial artery, and a Sentinel embolic protection device was placed over a Whisper J wire with baskets positioned in the innominate and left carotid arteries. ICE was used to assess the interatrial septum through a 10-Fr right common femoral vein sheath.
Using a medium-curl 8.5-Fr Agilis catheter and the back end of a 0.032-inch wire with electrocautery (Bovie, 40W cut), a transseptal puncture was performed. A 0.035-inch Toray wire was placed in the left atrium, and the interatrial septum was dilated with a 12 x 40-mm Charger balloon at 14 atm. A 7-Fr balloon wedge catheter was then advanced through the Agilis catheter, into the left atrium, across the mitral valve, and into the left ventricle ( Video 1 ). Through a telescoping system with the medium-curl 8.5-Fr Agilis sheath and a 4-Fr angled glide catheter, a 400-cm biliary wire was advanced into the ascending aorta; the wire was chosen for its length, stiffness, and compatibility with devices to be delivered over it. A 6-Fr multipurpose catheter and snare were advanced through a 6-Fr sheath in the left common femoral artery. The 400-cm wire was snared and externalized through the left femoral sheath, then secured.
Next, the Edwards SAPIEN 3 was delivered across the annulus with the 23-mm valve-mounted skirt-to-handle in order to deploy the valve in the correct orientation ( Videos 2 and 3 ). The Commander delivery system was turned 180 degrees so that the catheter would be flexed in the appropriate orientation. After confirming appropriate placement across the aortic valve using aortic root angiography, the valve was deployed with rapid ventricular pacing at 180 bpm ( Video 4 ).
Following valve deployment, transthoracic echocardiography and ICE revealed a well-placed and well-seated valve with no significant aortic regurgitation ( Videos 5 and 6 ). ICE demonstrated a bidirectional iatrogenic atrial septal defect ( Figure 2 ), and a 27-mm GORE CARDIOFORM Septal Occluder was placed ( Figure 3 , Video 7 ). Pressure waveforms immediately following valve deployment indicated successful resolution of the peak-to-peak pressure gradient across the aortic valve with similar preoperative and postoperative left ventricular end diastolic pressures ( Figure 4 ).
