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Pioneering transcatheter aortic valve Implant (Inovare®) via transfemoral

José Carlos Dorsa Vieira PontesI; João Jackson DuarteII; Augusto Daige da SilvaIII; Amaury Mont’Serrat Ávila Souza DiasII; Ricardo Adala BenfattiII; Neimar GardenalII; Amanda Ferreira Carli BenfattiIV; Jandir Ferreira Gomes JúniorII

DOI: 10.5935/1678-9741.20120078

ABBREVIATIONS AND ACRONYMS

TAVI: transcatheter aortic valve implantation

INTRODUCTION

The transcatheter aortic valve implantation has become a therapeutic option for patients with symptomatic severe aortic stenosis and high risk for conventional valve replacement surgery. Although balloon valvuloplasty have been the first option for less invasive treatment using percutaneous technique in critically ill patients, its longterm results have shown high rates of restenosis as well as not improving the clinical condition of the patients1, which makes this procedure only as an option for a bridge in emergency surgery. More recently the indication of transcatheter aortic valve implantation has been increased as repair of failed biological aortic prostheses in high risk for operation2.

 

CASE REPORT

75-year-old male patient presenting biological valve prosthesis in the aortic position number 25 placed 11 years ago. He was admitted in the coronary care unit of University Hospital, Federal University of Mato Grosso do Sul with pulmonary edema and acute severe aortic valve failure. Comorbidities such as renal failure not on dialysis, chronic obstructive pulmonary disease, severe left ventricular systolic dysfunction (ejection fraction 30%) made him a high-risk patients with Euroscore > 20%.

It was then performed transcatheter implantation of an aortic valve prosthesis: Braile Biomedica's INOVARE.

The inner diameter of aortic prosthesis (22 mm) was previously measured using echocardiography and angiography of multiple detectors. Therefore, we used a 24- prosthesis. The surgery was designed so that the implants were performed by transapical approach, however due to the team's experience with transfemoral access due to the endovascular treatment of aortic diseases, we chose to implant this device via tranfemoral in a pioneer way. We used a femoral sheath Gore Dry Seal 24 Fr where the prosthesis together with its delivery balloon was introduced via the right femoral artery and carried using an extrastiff guide through the aorta until the level of the aortic prosthesis' ring; under the guidance fluoroscopic and transesophageal echocardiography was expanded at the ring of the bioprosthesis. The echocardiographic images (Fig. 1) demonstrated the correction of severe aortic regurgitation without significant transvalvular gradient (15.20 mmHg) allowing, together with fluoroscopy (Fig. 2), to ensure the exact position of the prosthesis release and prove the effectiveness of the procedure when comparing the preoperative and postoperative images. After the procedure the patient was transferred to the coronary care unit, where he remained hospitalized for 2 days and discharged after three days of hospitalization.

 

 

 

 

DISCUSSION

Due to high mortality of severe symptomatic aortic stenosis especially in high surgical risk patients the possibility of less invasive intervention using transcatheter aortic valve implantation, either femoral or apical via, has become an attractive alternative.

The first description of the catheter valve implant was made by Davies3, 1965. Only in 2002, Cribier et al. [4] proposed the transcatheter aortic valve implantation (TAVI) to treat severe aortic stenosis in symptomatic patients with high surgical risk.

Partner Trial (Placement of Aortic Transcatheter) [5], the first "Trial" in its group B randomized trial, which compared medical therapy with transcatheter valve implantation, demonstrated superiority of the intervention, both in terms of mortality and quality of life. In group A the "trial" of transcatheter aortic valve implantation showed no inferiority when compared to open surgery in a year of follow-up of patients with critical aortic stenosis without surgical conditions.

In our environment Gaia et al6 reported a 30-day mortality found in 18.18% and overall mortality (42.42%) mainly attributed to infectious complications postoperatively. The fact that 39.39% of these patients underwent surgery in the presence of decomposition and prolonged hospitalization, induces a greater risk of colonization and infection. Survival after hospital discharge was quite favorable (90.7%), demonstrating that after the initial phase the result is sustained.

We believe that the idea of a new procedure is the trend that its appointment is reserved for exceptional cases, but it may cause a negative bias in the analysis of mortality. The accomplishment of this procedure in end stage of heart failure of clinically decompensated patients, surely contributes to the emergence of postoperative complications, perhaps these extremely critical patients could benefit only from balloon valvuloplasty as a bridge to either the transcatheter valve implantation.

The implant by transapical approach is often chosen due to the incompatibility with sheaths of larger caliber and decreases the possibility of peripheral vascular complications. However the development of endovascular materials, such as stents and introducers are allowing greater ease in using the femoral approach, this would minimize the harmful effects of thoracotomy on respiratory mechanics of these severe patients, which is known to be a risk factor for postoperative pulmonary infections. Further studies with larger samples are needed to define the safety of the procedure along with the sedimentation of technical learning in the future may allow this procedure be recommended for less critical and more electives patients.

REFERENCES

1. Otto CM, Mickel MC, Kennedy JW, Alderman EL, Bashore TM, Block PC, et al. Three-year outcome after balloon aortic valvuloplasty. Insights into prognosis of valvular aortic stenosis. Circulation. 1994;89(2):642-50. [MedLine]

2. Bedogni F, Laudisa ML, Pizzocri S, Tamburino C, Ussia GP, Petronio AS, et al. Transcatheter valve-in-valve implantation using Corevalve Revalving System for failed surgical aortic bioprostheses. JACC Cardiovasc Interv. 2011;4(11):1228-34. [MedLine]

3. Davies H. Catheter mounted valve for temporary relief of aortic insufficiency. Lancet. 1965;1:250. [MedLine]

4. Cribier A, Eltchaninoff H, Bash A, Borenstein N, Tron C, Bauer F, et al. Percutaneous transcatheter implantation of an aortic valve prosthesis for calcific aortic stenosis: first human case description. Circulation. 2002;106(24):3006-8. [MedLine]

5. Leon MB, Smith CR, Mack M, Miller DC, Moses JW, Svensson LG, et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med. 2010;363(17):1597-607. [MedLine]

6. Gaia DF, Palma JH, Ferreira CB, Souza JA, Agreli G, Guilhen JC, et al. Implante transapical de valva aórtica: resultados de uma nova prótese brasileira. Rev Bras Cir Cardiovasc. 2010;25(3):293-302. [MedLine] View article

Article receive on Saturday, May 26, 2012

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