Abstract
Despite the widespread use of transcatheter aortic valve replacement (TAVR) for moderate and high-risk patients with severe aortic stenosis, it is utilized less frequently in patients with bicuspid aortic valves (BAV). Orthotopic heart transplant (OHT) donors tend to be younger and may have undiagnosed BAV. We present a case of successful TAVR in a patient with BAV thirteen years after OHT.
Highlights
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This case report documents the rare occurrence of a bicuspid aortic valve in a donor heart and the potential for this valve to become stenotic in a recipient 13 years after transplant.
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Transcatheter aortic valve replacement was utilized to treat severe and symptomatic bicuspid aortic stenosis in a transplant recipient.
Although bicuspid aortic valves (BAV) affect only 1–2% of the general population , up to 50% of adults with severe, symptomatic aortic stenosis undergoing surgical aortic valve replacement (AVR) may have BAV . Given this frequency and the increasing survival for patients after orthotopic heart transplantation (OHT), it is important for clinicians to recognize the potential for aortic stenosis due to BAV in this population. There have been case reports of open AVR after cardiac transplant for BAV . However, prior sternotomy, immunosuppression, and other co-morbidities in this population may preclude AVR as a low risk option. We present a case of successful TAVR in BAV 13 years post-cardiac transplant.
Our patient is a 73 year old male who developed a dilated cardiomyopathy with left ventricular failure three years after AVR for aortic regurgitation. He underwent uncomplicated OHT in 2003 from a 46 year old male donor. His initial post-operative echocardiogram showed an ejection fraction (EF) of 85% with normal aortic valve function. In 2005, the aortic valve was noted to be possibly bicuspid with mild thickening and calcification, but without significant stenosis or regurgitation ( Fig. 1 A ). In 2009, the mean transaortic gradient was 14 mmHg, and subsequent annual measurements demonstrated increasing gradient and a progressive decrease in valve area. In 2016, the patient reported DOE and the mean transaortic valve gradient was 43 mmHg with a calculated valve area of 0.58 cm 2 . The Society of Thoracic Surgery (STS) predicted risk of 30 day mortality was 8.024%, primarily due to two prior sternotomies. TAVR was considered as an option in this high risk surgical candidate by the heart valve team with careful review of his 3D reconstructed multi-slice chest computed tomography angiogram (CTA) ( Fig. 1 B). Recent papers have highlighted the importance of rigorous assessment of the BAV and CTA for proper sizing in order to reduce paravalvular regurgitation . Although his measured annulus area (444 mm2) was most compatible with a #26 Sapien 3 TAVR prosthesis, intra-operative balloon sizing with a 23 mm diameter balloon was utilized to confirm splitting of the raphe ( Fig. 2 A ) after which a #26 prosthesis was implanted with an excellent result ( Fig. 2 B). Post-operative echocardiogram demonstrated a well seated valve with peak gradient of 27 mmHg and mean gradient of 13 mmHg. There was no valvular or paravalvular regurgitation. Patient was discharged on post-operative day 2. This report demonstrates the feasibility of TAVR in a transplant patient with BAV in the donor heart.
