Feasibility of transapical aortic valve replacement through a left ventricular apical diverticulum.

2 MB·English

by  Ferrari, Enrico

Ferrarietal.JournalofCardiothoracicSurgery2013,8:3
http://www.cardiothoracicsurgery.org/content/8/1/3
CASE REPORT Open Access
Feasibility of transapical aortic valve replacement
through a left ventricular apical diverticulum
Enrico Ferrari*, Mathieu Van Steenberghe, Jegaruban Namasivayam, Denis Berdajs, Lars Niclauss
and Ludwig Karl von Segesser
Abstract
Transapical aortic valve replacement is anestablishedtechnique performed inhigh-risk patients withsymptomatic
aortic valve stenosis and vascular disease contraindicatingtrans-vascular and trans-aortic procedures. The presence
ofa left ventricular apical diverticulumis a rare event and thetreatment depends on dimensions and estimated risk
ofembolisation, rupture, or onset ofventricular arrhythmias.The diagnosis is based onstandard cardiac imaging
and symptoms are very rare. In this case report we illustrate our experience with a 81 years old female patient
suffering from symptomatic aortic valve stenosis, respiratory disease, chronicrenalfailure and severe peripheral
vascular disease (logistic euroscore: 42%), who successfully underwent a transapical 23 mmballoon-expandable
stent-valve implantation through an apical diverticulum oftheleft ventricle. Intra-luminal thrombi were absent and
during the same procedure were able to treat thevalve disease and to successfully exclude theapical diverticulum
without complications and through a minithoracotomy.To thebest of our knowledge, this is the firsttime that a
transapical procedure is successfully performed through an apical diverticulum.
Keywords: Aortic valve replacement, Transcatheter aortic valve implantation,Left ventricular apical diverticulum
Background ventricular apical diverticulum without apical thrombi,
Transcatheter aortic valve replacement (TAVR) is an and that the apical diverticulum can be excluded during
established minimally invasive technique for patients thesameprocedure.
with severe symptomatic aortic valve stenosis and surgi-
Case presentation
cal high-risk profile. Predominant accesses are the trans-
An81yearoldfemalewithseveresymptomaticaorticvalve
apical and the transfemoral ones, but, recently, also the
stenosis was screened for a transcatheter aortic valve pro-
trans-subclavian and the trans-aortic access have been
cedure. She carried several comorbidities: severe obstruct-
employed to perform successful transcatheter aortic
ive respiratory disease, peripheral vascular disease with
valve procedures. However, severe atherosclerosis, heavy
small calcified femoral arteries, small subclavian arteries
calcifications, small diameters and tortuosities limit the
and diseased ascending aorta, contraindicating all trans-
trans-vascular and the trans-aortic access, whereas a left
vascularapproaches.Moreover,adiffuse coronarysclerosis
ventricular dysfunction, presence of apical thrombi
without significant stenosis was diagnosed, and the patient
and anatomical left ventricular anomalies (such as an
alsosufferedfromachronickidneyfailuresothatweopted
aneurysm or an apical diverticulum) can constrain the
for a transapical procedurefully guided by transesophageal
transapical approach [1]. Recently, we already demon-
echocardiography without intraoperative angiographies.
strated that TAVR can be safely performed through a
Duringthepreoperativeimagingassessment,weperformed
chronic left ventricular apical aneurysm, as long as apical
a computed tomography scan with low contrast that
thrombiareabsent[2].Inthisnewreport,andforthefirst
revealedthepresenceofacongenitalapicaldiverticulumof
time ever, we show the proof that a transapical aortic
the left ventricle without thrombi. Diameters were 13 mm
valve procedure can be safely performed through a left
and16mm(Figure1A).Theechocardiogramshowedase-
verely degenerated and much calcified aortic valve with
*Correspondence:[email protected]
trans-valvular peak gradient of 53 mmHg, surface area of
DepartmentofCardiovascularsurgery,CHUV,UniversityHospitalof
Lausanne,RueduBugnon46,LausanneCH-1011,Switzerland 0.6 cm2, left ventricular ejection fraction of 65% and
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Ferrarietal.JournalofCardiothoracicSurgery2013,8:3 Page2of3
http://www.cardiothoracicsurgery.org/content/8/1/3
Figure1A)Acomputedtomographyscanshowingtheleft
ventricularapicaldiverticulum:notetheabsenceofthrombi. Figure2A)Intraoperativeviewshowingtheintroductionof
B)Intraoperativeviewofthecardiacapex:macroscopically,thereis thedeliverysystem(Ascendra™2)intheapex.B)Fluoroscopic
noevidenceofadiverticulum,whereasthepalpationrevealsasoft viewofthestent-valvedeploymentunderrapidpacing.
portion.C)Carefulpreparationofadoublepledgeted3–0Prolene C)Postoperativecomputedtomographyscanshowingthegood
purse-stringsuturearoundthediverticulum. resultwithpartialexclusionofthediverticulum.
Ferrarietal.JournalofCardiothoracicSurgery2013,8:3 Page3of3
http://www.cardiothoracicsurgery.org/content/8/1/3
pulmonary hypertension. The apical diverticulum was not In our experience, we prepared two larger pledgeted
visualized.Thepatientacceptedatransapicalaorticproced- purse-string sutures in order to detect good thick
urethroughtheleftventriculardiverticulumandthecalcu- myocardium surrounding the diverticulum: using this
latedoperativeriskwas42%(logisticEuroSCORE). stratagem, part of the diverticulum was successfully
The transapical stent-valve procedure was performed excluded when the sutures were tied and we did not
undergeneralanesthesiaandintheoperatingroom.From experiencedapical bleeding.
a surgical point of view, the apical approach was unevent- With regards to the postoperative management, we
ful: macroscopically (Figure 1B), we did not observed any did not change our protocols but we performed a com-
external sign of the presence of the diverticulum, whereas puted tomography scan to visualize the resulting apical
theapicalpalpationrevealedathinnerwallina2cm2wide anatomy. In conclusion, TAVR procedures can be safety
region. There were no adhesions in the pericardium. A and efficacy performed through a left ventricular apical
doublepledgetedpurse-stringsuturewith3–0Prolenewas diverticulum,intheabsenceofintraluminalthrombi.
carefully and successfully performed around that area
(wherethemyocardiumwasticker).Then,thedeliverysys- Consent
™
tem(Ascendra 2)wasintroduced,uneventfully,intheleft Thepatientgavehisinformedconsentfor publication.
ventricle through the diverticulum (Figures 1C and 2A).
™ Competinginterests
Following the standard technique a 23 mm Sapien XT
EFisconsultantforEdwardsLifesciences.
stent-valve(EdwardsLifesciencesInc.,Irvine,CA)wassuc-
cessfullyimplantedwithfinaltrans-valvularmeanandpeak Authors’contribution
AllAuthorsequallycontributedtothispaper.Allauthorsreadandapproved
gradients of 10/4 mmHg (Figure 2B). Then, the delivery
thefinalmanuscript.
system was retrieved and the apical sutures were tided
underrapidpacing.Theentireprocedurerequired80min- Received:12July2012Accepted:17December2012
Published:7January2013
utes to be performed and we did not experienced apical
complications. A postoperative scan confirmed the stent- References
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apex [5]. There is no consensus about the treatment of Citethisarticleas:Ferrarietal.:Feasibilityoftransapicalaorticvalve
replacementthroughaleftventricularapicaldiverticulum.Journalof
this ventricular anomaly and the management should be
CardiothoracicSurgery20138:3.
tailored to the clinical characteristics of each patient,
taking into consideration the onset of potential compli-
cations (embolization, rupture, ventricular arrhythmias) Submit your next manuscript to BioMed Central
[6]. The surgical treatment consists of an excision and and take full advantage of:
placementofapatch.
During a transapical transcatheter aortic valve replace- • Convenient online submission
ment, the apex is prepared with two purse-string sutures • Thorough peer review
andthenpuncturedinordertointroducethedeliverysys- • No space constraints or color figure charges
tem. Thus, in the presence of a diverticulum without • Immediate publication on acceptance
intraluminal thrombi, and inthe absence ofgood alterna- • Inclusion in PubMed, CAS, Scopus and Google Scholar
tive vascular and accesses, the transapical approach • Research which is freely available for redistribution
appears to be adequate in order to treat, simultaneously,
boththeapicaldiverticulumandtheaorticvalvestenosis. Submit your manuscript at
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