Clinical trial registration: None
We
presented a case of TAVR with an extreme low-placed Venus A-Valve in a
cardiogenic shock patient with the approval from institutional review
board and informed consent. A 64-year-old man with a history of
hypertension, gastrointestinal bleeding and chronic kidney disease
presented to our emergency complaining of orthopnea and fatigue with
progressive aggravation in the last one month. He had acute upper
gastrointestinal bleeding and underwent medical treatment one month ago.
On physical examination we documented a mid-systolic murmur along the
upper right sternal border and pansystolic murmur over the apex. He was
in heart failure with coarse crackling and wheezing in both lungs. He
had New York Heart Association class IV symptoms with EuroSCORE II of
20%. He had a lean figure with a height of 175 cm and a weight of 53
Kg.
Transthoracic echocardiography (TEE) demonstrated severe aortic stenosis
(AS) and severe mitral regurgitation (MR) with left ventricular ejection
fraction of 46% (left ventricular end-diastolic diameter: 58mm, left
ventricular end-systolic diameter: 45mm, aortic valve mean pressure
gradient: 50mmHg, aortic valve Vmax: 455cm/s, mitral valve
regurgitation: 3+). Mitral valve was showed with poor coaptation of the
leaflets. Contrast-enhanced computed tomography (CT)-derived annular
area perimeter measurements were 428.9mm2 and 74.8mm
(Figure 1), respectively, mandating a 22mm Venus balloon to predilate
and a 26 mm Venus A-Valve to implant.
The patient’s symptoms, frailty, the burden of comorbidities and
technical aspects were evaluated by a multidisciplinary heart team. The
heart team decided to proceed with urgent TAVR of a Venus A-Valve (Venus
MedTech, Hangzhou, China) and evaluated the mitral regurgitation after
TAVR to determinate the staged therapy. Preoperative management included
inotropic therapy, morphine injection and blood transfusion. Procedure
was performed under general anesthesia in hybrid operating room.
Immediately following exposure of right femoral artery, the systolic
pressure failed to rise above 40 mmHg. Balloon aortic valvuloplasty was
performed using a 22mm Venus balloon in a short time. After
pre-dilation, the patient developed shock and arrested. Cardiopulmonary
resuscitation was commenced. Meanwhile the 26 mm Venus A-Valve was
deployed. Extracorporeal circulation was established. Aortography and
TEE illustrated an extreme low implantation (Figure 1) and moderate to
severe “supra-skirt” paravalvular aortic regurgitation (PAR) (Figure 2
and Figure 3)(1). TEE in short-axis view showed a
moderate to severe PAR originated from the right coronary cusp and mild
prosthetic aortic valve stenosis (aortic valve mean pressure gradient:
29mmHg, aortic valve Vmax: 339cm/s). After evaluating the hemodynamic
tolerability of PAR, moderate prosthesis-patient
mismatch(2), the initial severe mitral regurgitation
and potential influence for the movement of the anterior leaflet of
mitral valve due to the low deployment, the heart team decided to
proceed with aortic valve replacement and mitral valve replacement
rather than valve-in-valve TAVR(3). A median
sternotomy was done and Venus A-Valve was removed after infiltration by
ice water (Figure 4). A 25mm St. Jude Medical mechanical mitral
prosthesis and a 19 mm St. Jude Medical Regent aortic prosthesis were
implanted (St Jude Medical, Inc., St Paul, Minn, USA). The
cross-clamping time was 105 min and the cardiopulmonary bypass time was
245 min.
TAVR may be an option for patients in high surgical risk with
cardiogenic shock (CS) and severe aortic stenosis. The final depth of
the Venus A-Valve bioprosthesis is the predictor of paravalvular aortic
regurgitation and is associated with prosthesis-patient mismatch (P-PM).
P-PM is an essential determinant of morbidity and mortality following
TAVR. A widespread and practical percutaneous technique to manage the
implant failure of TAVR is required to avoid the surgical bailout.