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TAVI in type I bicuspid complex aortic valve with balloon-expandable valve

Diego Nicolás Areco, Aldo Michael Rodríguez Saavedra, Marisa Malvina Acosta, Alejandra Soledad Vega

Revista Argentina de Cardioangiologí­a Intervencionista 2023;(2): 0073-0074 | Doi: 10.30567/RACI/20232/0073-0074


Transcatheter aortic valve implantation (TAVI) is a challenge when dealing with bicuspid aortic valve (BAV) anatomies. Patients are young, the morphological phenotypes are many, the calcium load is high, and there are technical considerations to obtain better results. However, we have no prospective randomized clinical data with this treatment approach. Observational studies and registries are available with data and favorable clinical experiences worldwide.
This is the case of a young patient with type I bicuspid aortic stenosis and severe coronary artery disease who underwent PCI + TAVI.


Palabras clave: aortic valve stenosis, transcatheter aortic valve implantation, bicuspid aortic valve.

El implante transcatéter de válvula aórtica (TAVI) representa un desafío en la anatomía de la válvula aórtica bicúspide (BAV). Los pacientes son jóvenes, los fenotipos morfológicos son muchos, la carga de calcio es alta y existen consideraciones técnicas para obtener mejores resultados5. No existe data clínica prospectiva aleatorizada con este enfoque de tratamiento. Estudios y registros observacionales están disponibles con datos y experiencias clínicas favorables de todo el mundo.
Presentamos el caso de una paciente joven con estenosis aórtica bicúspide tipo I y enfermedad arterial coronaria severa a la que se le realizó PCI+TAVI.


Keywords: estenosis valvular aórtica, reemplazo valvular aórtico transcatéter, válvula aórtica bicúspide.


Los autores declaran no poseer conflictos de intereses.

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Recibido 2023-03-22 | Aceptado 2023-05-31 | Publicado


Licencia Creative Commons
Esta obra está bajo una Licencia Creative Commons Atribución-NoComercial-SinDerivar 4.0 Internacional.

Introduction

Bicuspid aortic valve (BAV) is the most common congenital valvular heart disease and is present in almost 50% of patients eligible for aortic valve replacement. While transcatheter aortic valve implantation (TAVI) is an established treatment for severe symptomatic aortic stenosis (AS) in all levels of surgical risk, experience with TAVI in the management of severe bicuspid AS is limited and remains challenging due to its association with multiple and complex anatomical considerations.1 The purpose of this publication is to introduce a challenging case of a young woman with severe type I bicuspid aortic stenosis and stable symptomatic severe coronary artery disease treated with TAVI.

Case report

This is the case of a 62-year-old woman with cardiovascular risk factors: AHT, dyslipidemia, and a past medical history of mixed connective tissue disease (MCTD), group 1 pulmonary hypertension, type I bicuspid aortic valve stenosis.

She presented with progressive dyspnea and angina and NYHA FC III/IV of a 1-year history. Doppler echocardiography revealed the presence of aortic stenosis progressing into its severe grade, derivation of continuity equation area of 0.4 cm², mean gradient of 60 mmHg, mild-to-moderate aortic regurgitation, LVH, left ventricular ejection fraction of 68% without regional wall motion abnormalities. The mitral valve remained sclerocalcific with mild mitral regurgitation and mild tricuspid regurgitation, estimating a SPAP of 35 mmHg. Right heart chambers looked normal with preserved right ventricular systolic function. The cine coronary arteriography performed revealed the presence of severe obstructive coronary artery disease of 2 main vessels: the proximal left anterior descending coronary artery (LAD) in bifurcation with a diagonal branch (MEDINA 1.1.1) and the mid section of the right coronary artery (RCA).

Tomographic analysis confirmed the presence of type I bicuspid anatomy (Sievers classification), severely calcified bicommissural valve with a non-calcified raphe (Jilaihawi et al.),4 elliptical and slightly horizontal shape, with calcium in the annulus and LVOT. The following measurements were taken: perimeter, 78.2 mm; area, 456 mm²; perimeter-derived diameter, 24.9 mm; area-derived diameter, 24.1 mm. Measurements were taken according to the LIRA 3 plane method, intercommissural distance, 24 mm; left coronary height, 12 mm; right coronary height, 14 mm. Sinus diameters: non-coronary, 33 mm; right coronary, 27 mm; left coronary, 28 mm. The caliber of femoral accesses was appropriate. Membranous septum thickness was 3.3 mm, and the ECG showed a baseline right bundle branch block (estimated intermediate risk of complete heart block during and post-implantation).

The EuroSCORE was estimated at 4.1%, the STS Score at 2.51%, and the Afilalo test equalled 2 points (intermediate frailty). Despite of this, the patient was considered of high surgical risk due to comorbidities unaccounted for in these conventional surgical risk scores and fragility. The case was discussed with the heart team including the rheumatologist. A decision was made to perform PCI + TAVI.

In the first surgical act, a PCI was performed using the bifurcation technique (provisional stenting). A 3.0 mm x 18 mm rapamycin-eluting cobalt-chromium stent was implanted in the proximal third of the left anterior descending coronary artery followed by a 3.0 mm x 22 mm zotarolimus-eluting DES in the mid section of the right coronary artery.

In the second surgical act (30 days later), TAVI was performed using a conventional technique. The patient was under general anesthesia. Right femoral access was used and an 8-Fr valved femoral introducer sheath was inserted. Also, via left femoral access, a 6-Fr valved femoral introducer sheath was inserted. A 5-Fr J-tipped pigtail catheter was mounted over a 0.035 in support guidewire and then advanced and placed in the non-coronary sinus for angiographic testing. Via right femoral access, a 2-Fr AR catheter was mounted over a 180 cm straight hydrophilic 0.035 support guidewire and advanced towards the left ventricle. Afterwards, it was then exchanged for a second Pigtail catheter. Simultaneous invasive pressures were monitored pre-implantation: LV, 200 mmHg; aorta, 100 mmHg; gradient, 100 mmHg. The Confida guidewire (Medtronic, Minneapolis, United State) was exchanged, and the 8-Fr introducer sheath was replaced by a 14-Fr Phyton introducer. After pre-dilatation with a 20 mm Mammoth balloon, the Navigator delivery system with a crimped Myval balloon-expandable valve of 24.5 mm was advanced and positioned into the valvular plane. After proper angiographic testing, it was successfully released under fluoroscopic control and high-frequency pacing (180 bpm). The ECG showed sinus rhythm with baseline right bundle branch block. Hemodynamic stability was achieved. Peak-to-peak gradient post-implantation was 4 mmHg. Doppler echocardiography showed a mean gradient of 8 mmHg, a maximum velocity of 1.9 m/s, and trivial leakage. Surgical closure of the arteriotomy was performed. After recovering from anesthesia, the patient remained awake and without neurological deficits upon leaving the cath lab. Hospital discharge occurred without complications at 24 hours.

Discussion

We presented a challenging case of a young patient with complex type I bicuspid anatomy and associated coronary artery disease who underwent PCI+TAVI with favorable procedural, hemodynamic, and clinical outcomes (VARC-3). This case presents 4 different challenges: First (Clinical) TAVI vs conventional SAVR; no prospective randomized piece of information has ever compared this approach to SAVR, the latter with well-established evidence in all risk groups. However, clinical experience with TAVI in BAV is on the rise proving to be safe and effective compared to tricuspid anatomy to the extent that data from the largest registry ever published to this date, STS/ACC TVT on this therapy has raised the level of recommendation in the latest American Valvular Heart Disease Clinical Practice Guideline (2021).8 The second challenge (Bicuspid anatomy) involves asymmetry of valve opening, fused raphe, differential depths and dimensions of sinuses, significant calcifications, and associated aortopathy, and the likely presence of associated abnormal coronary origin. These anatomical limitations can potentially lead to the asymmetric expansion of the implanted device, which in turn requires aggressive post-dilatation to treat residual gradients or paravalvular leaks. In addition, poor long-term expansion may result in flow abnormalities, device thrombosis, and early structural valve deterioration, ultimately affecting device durability.1 The third topic under discussion is the selection of type and size of transcatheter heart valve. We selected a 24.5 mm + 1 mm balloon-expandable valve (Myval Meril Life), which gave us a 6% oversizing, which is in full compliance with the recommendations given for this type of valve and anatomy. This valve comes in intermediate sizes too, which would theoretically be a phenomenal plus for this type of anatomy, avoiding over- or undersizing and optimizing the valve-patient interaction. The balloon-expandable system balances the risk of annular rupture with less paravalvular leak. Secondarily, it theoretically offers better future coronary reaccess thanks to its intra-annular valve design and low height of the stent frame (feature shared with the Edwards Sapien valve). The fourth challenge (Management of stable coronary artery disease) involved the decision to perform PCI before TAVI, which offered the advantages of easier coronary access, lower risk of ischemia driven hemodynamic instability (during rapid pacing), and reduced contrast use compared to concomitant TAVI and PCI. This decision was made because the patient was a young individual with long life expectancy, symptomatic angina, and presence of complex proximal bifurcation lesion in the left anterior descending coronary artery.

Conclusion

In this patient, TAVI turned out to be a safe and effective procedure. We should mention the significance of meticulous planning for proper device selection considering the unpredictable early anatomy.

References

1. Elkoumy A, Jose J, Terkelsen CJ, et al. Safety and Efficacy of Myval Implantation in Patients with Severe Bicuspid Aortic Valve Stenosis-A Multicenter Real-World Experience. J Clin Med. 2022 Jan 15;11(2):443. doi: 10.3390/jcm11020443. PMID: 35054137; PMCID: PMC8779274.

  1. Elkoumy A, Jose J, Terkelsen CJ, et al. Safety and Efficacy of Myval Implantation in Patients with Severe Bicuspid Aortic Valve Stenosis-A Multicenter Real-World Experience. J Clin Med. 2022 Jan 15;11(2):443. doi: 10.3390/jcm11020443. PMID: 35054137; PMCID: PMC8779274.

  2. Forrest JK, Kaple RK, Ramlawi B, et al. Transcatheter aortic valve replacement in bicuspid versus tricuspid aortic valves from the STS/ACC TVT registry. Cardiovascular Interventions 2020;13(15):1749-59.

  3. Gorla R, Casenghi M, Finotello A, et al. Outcome of transcatheter aortic valve replacement in bicuspid aortic valve stenosis with new-generation devices. Interactive cardiovascular and thoracic surgery 2021;32(1):20-8.

  4. Iannopollo G, Romano V, Esposito A, et al. Update on supra-annular sizing of transcatheter aortic valve prostheses in raphe-type bicuspid aortic valve disease according to the LIRA method. Eur Heart J Suppl. 2022 May 18;24(Suppl C):C233-C242. doi: 10.1093/eurheartj/suac014. PMID: 35602251; PMCID: PMC9117906.

  5. Kumar V, Sengottuvelu G, Singh VP, Rastogi V, Seth A. Transcatheter Aortic Valve Implantation for Severe Bicuspid Aortic Stenosis - 2 Years Follow up Experience From India. Front Cardiovasc Med. 2022 Jul 28;9:817705. doi: 10.3389/fcvm.2022.817705. PMID: 35966565; PMCID: PMC9369256.

  6. Tarantini G, Tang G, Blackman D, et al. (2023). Management of coronary artery disease in patients undergoing transcatheter aortic valve implantation. A clinical consensus statement from the European Association of Percutaneous Cardiovascular Interventions in collaboration with the ESC Working Group on Cardiovascular Surgery. EuroIntervention: journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology, EIJ-D.

  7. Williams MR, Jilaihawi H, Makkar R, et al. The PARTNER 3 bicuspid registry for transcatheter aortic valve replacement in low-surgical-risk patients. Cardiovascular Interventions 2022;15(5):523-32.

  8. Writing Committee Members, Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Journal of the American College of Cardiology 2021;77(4):e25-e197.

  9. Yeats BB, Yadav PK, Dasi LP, Thourani VH. Transcatheter aortic valve replacement for bicuspid aortic valve disease: does conventional surgery have a future? Annals of Cardiothoracic Surgery 2022;11(4):389.

  10. Zhang Y, Xiong TY, Li YM, et al. Patients with bicuspid aortic stenosis undergoing transcatheter aortic valve replacement: a systematic review and meta-analysis. Frontiers in Cardiovascular Medicine 2022;9.

Autores

Diego Nicolás Areco
Hospital de Alta Complejidad “Pte. Juan Domingo Perón”. Formosa Capital, Formosa.
Aldo Michael Rodríguez Saavedra
Hospital de Alta Complejidad “Pte. Juan Domingo Perón”. Formosa Capital, Formosa.
Marisa Malvina Acosta
Hospital de Alta Complejidad “Pte. Juan Domingo Perón”. Formosa Capital, Formosa.
Alejandra Soledad Vega
Hospital de Alta Complejidad “Pte. Juan Domingo Perón”. Formosa Capital, Formosa.

Autor correspondencia

Diego Nicolás Areco
Hospital de Alta Complejidad “Pte. Juan Domingo Perón”. Formosa Capital, Formosa.

Correo electrónico: nico_areco@hotmail.com / docenciahacfsa@gmail.com

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TAVI in type I bicuspid complex aortic valve with balloon-expandable valve

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Revista Argentina de Cardioangiología intervencionista, Volumen Año 2023 2

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Revista Argentina de Cardioangiología intervencionista
Issue # 2 | Volumen 13 | Año 2023

Etiquetas

aortic valve stenosis, transcatheter aortic valve implantation, bicuspid aortic valve

Tags

estenosis valvular aórtica, reemplazo valvular aórtico transcatéter, válvula aórtica bicúspide

Titulo
TAVI in type I bicuspid complex aortic valve with balloon-expandable valve

Autores
Diego Nicolás Areco, Aldo Michael Rodríguez Saavedra, Marisa Malvina Acosta, Alejandra Soledad Vega

Publicación
Revista Argentina de Cardioangiología intervencionista

Editor
Colegio Argentino de Cardioangiólogos Intervencionistas

Fecha de publicación
2023-06-30

Registro de propiedad intelectual
© Colegio Argentino de Cardioangiólogos Intervencionistas

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