Valve-in-Valve Transapical Transcatheter Aortic Valve Replacement with Concomitant Percutaneous Coronary Intervention: A Case Report

Introduction

Aortic stenosis has a prevalence as high as 13.1% in patients over 75 years of age [1]. Valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) is becoming more common in high-risk patients with previous bioprosthetic AVR and required repeat interventions. Transfemoral access for TAVR is the current standard approach in most settings; however, contraindications, such as peripheral artery disease, prevent transfemoral access in up to 20% of patients [2,3]. For TAVR patients, alternate access options are essential, with transsubclavian, transcarotid, transaortic, transapical, and transcaval approaches having been described previously [4–6]. While transapical TAVR was among the first approaches used for TAVR, this approach has fallen out of favor, with improved outcomes demonstrated following other alternative approaches, such as transsubclavian or transcarotid [4–6]. While alternative vascular approaches, including transcarotid and transsubclavian approaches, are feasible in most settings, some patients with severe peripheral vascular disease do not have any suitable vascular access sites for TAVR. In these cases, the transapical approach provides an alternative that can be used even in the setting of diffuse vascular disease. Given its infrequent use, transapical TAVR has not regularly been used for ViV-TAVR, and cases of concomitant percutaneous coronary intervention (PCI) in this setting are even less common. In this report, we describe the complex case of a 79-year-old man who received transapical ViV-TAVR with PCI.

Case Report

INVESTIGATIONS:

The patient’s comorbidities included hypertension, dyslipidemia, basilar artery aneurysm, and lung nodules. He also had a history of coronary artery disease, with PCI 22 years prior and coronary artery bypass grafting with bioprosthetic AVR 9 years prior. Preoperative echocardiogram findings included left ventricular ejection fraction of 55%, prosthetic aortic valve stenosis with a mean gradient of 37 mmHg, valve area of 0.9 cm², and maximum velocity of 4 m/s, suggesting severe prosthetic valve stenosis. Cardiac catheterization revealed an occluded right coronary artery, occluded saphenous vein graft to the posterior descending artery, and moderate stenosis of the left anterior descending artery and first diagonal artery.

A 12-lead electrocardiogram showed sinus rhythm with inferior Q-waves. A computed tomography scan demonstrated severe stenosis with moderate calcification in the proximal left and right common iliac arteries with diameters of 5 mm, which were considered a contraindication to the transfemoral approach to TAVR. Additionally, there was calcification at the base of the aortic arch and including the left common carotid and subclavian arteries. These findings were also viewed as contraindications to transcarotid and transsubclavian approaches to TAVR. Coronary ostial heights were 9 mm on the left and 12 mm on the right. His Society of Thoracic Surgeons risk score was 14%. With the contraindications to transfemoral and alternative vascular approaches to TAVR, a transapical approach was decided, following a discussion with the heart team and the patient.

MANAGEMENT:

The patient was brought to the operating room for an elective ViV transapical TAVR. Prior to prepping the patient, the left ventricular apex was marked under fluoroscopic guidance. A left anterior mini-thoracotomy in the fifth interspace was made. Epicardial pacing wires were placed on the left ventricle and tested. The patient was administered 90 units/kg of heparin. Two 3-0 polypropylene (Ethicon, New Jersey, USA) purse-string sutures were placed in the left ventricular apex and snared. The right common femoral artery was punctured, but a wire could not be advanced. The left common femoral artery was accessed, although a guide catheter would not advance, given the severe peripheral vascular disease; therefore, a 7 French sheath and pigtail were placed. Right radial artery access was obtained.

The apex was then accessed under fluoroscopic guidance using the Seldinger technique, placing a 7 French sheath. A J-tip wire was placed from the apex across the bioprosthetic aortic valve into the descending thoracic aorta. A Judkins right catheter was placed over the regular J-wire. The regular J-wire was replaced with an Amplatz extra-stiff wire. A 26-mm Sapien S3 valve (Edwards Lifesciences, CA, USA) was then brought into the introducer sheath. The TAVR valve was positioned and deployed under rapid pacing at 180 beats per minute (Figure 1). The TAVR apparatus was removed under rapid pacing, and the purse-string sutures tied. There was no significant bleeding from the access site. An aortic root angiogram was performed, showing the possibility of left main occlusion. A left main snorkel stent was deployed for left main protection. Intraoperative transesophageal echocardiogram (TEE) reported trivial paravalvular leak, good valve positioning, and a mean gradient of 7 mmHg across the valve (Figure 2).

Hemostasis was achieved, and a single chest tube was placed in the left chest. The epicardial left ventricular pacing wires were exteriorized and capped. The left anterior mini-thoracotomy was closed without issue. The left common femoral artery puncture site was then closed with 6 French Angio-Seal device (Terumo Corporation, Tokyo, Japan). A left paravertebral block was performed for postoperative pain control.

The patient was transferred to the Coronary Care Unit in stable condition.

FOLLOW-UP:

The patient was extubated within 8 h, without respiratory complications. On postoperative day 0, the patient had several episodes of hematemesis. Endoscopy was performed, which identified edematous and friable esophageal mucosa, which was believed to be the cause of his upper gastrointestinal bleed. This was thought to be related to trauma from the TEE, although no further intervention was required other than a single unit of red blood cell transfusion for anemia. Postoperative TTE found an left ventricular ejection fraction 50% to 55% and did not identify prosthetic aortic valve regurgitation. His total hospital length of stay was 8 days, and he was discharged in stable condition. The patient did not have any complications related to his TAVR during the year following his procedure. His symptoms of dyspnea gradually improved following discharge. Unfortunately, the patient died approximately 1 year after surgery from an unrelated event.

Discussion

In this case report, we describe a case of transapical ViV-TAVR with concomitant left main PCI. This patient was at high surgical risk; however, due to his computed tomography findings of poor femoral access, he was also not a candidate for transfemoral TAVR or other alternatives, such as transcarotid or transsubclavian access. This report highlights a case of successful transapical ViV-TAVR with PCI, illustrating the importance of a large arsenal of access options for TAVR to treat patients with severe aortic stenosis with contraindications to other approaches.

With TAVR becoming a widespread, effective, and safe option for AVR in high-risk patients, further applications of this technique are also becoming more common, such as ViV-TAVR. The outcomes following ViV-TAVR have previously been reported from large registries, such as in the report by Bleiziffer et al. In their study, data were collected from 180 centers and included 1006 cases. In the series, the mean age was 78 years and the Society of Thoracic Surgeons risk score was 7.3%. Survival at 8 years of 38.0% and median survival was 6.2 years, although freedom from reintervention at 8 years was 93% [7]. The limited long-term survival is likely in part due to the associated patient population that is often of advanced age and high or prohibitive risk for surgical intervention.

The ViV approach is regularly used; however, it is infrequently used from alternative approaches, and even less so from the transapical approach. PCI has previously been demonstrated to be safe when performed concomitantly with TAVR, although its use in a complex reoperative setting such as the one described in this case is relatively limited [8]. While transfem-oral TAVR is the standard access for TAVR, 20% of these patients have contraindications to transfemoral access [5]. While transapical TAVR has fallen out of favor as an initial choice of approach for TAVR, it is still used in patients with contraindications to transfemoral and alternative access and can be used for ViV-TAVR safely, as described in this case. The trans-apical approach is a reasonable alternative for high-risk redo AVR in patients unsuitable for transfemoral TAVR or other alternate access.

Conclusions

Aortic stenosis is a common cardiac disease process, with many elderly and high-risk patients requiring AVR. Within this population, however, some patients are ineligible for transfemoral TAVR, due to poor femoral access and unsuitable anatomy. We presented a case of transapical ViV-TAVR with PCI, demonstrating the success of this alternative approach in a ViV procedure, where no other options were feasible. This case highlights the importance of having available a large arsenal of surgical and interventional approaches to tailor valve interventions for the patient.