A Transcatheter Aortic Valve Implantation Without Aortography Guidance Due To Vascular Access Constraints Or Limitations

Mailing Adress: Levent Cerit Near East University. Postal Code 07100, Nicosia – Chipre E-mail: drcerit@hotmail.com, drcerit@yahoo.com A Transcatheter Aortic Valve Implantation Without Aortography Guidance Due To Vascular Access Constraints Or Limitations Oktay Ergene,1 Hamza Duygu,2 Volkan Emren,3 Ugur Kocabas,4 Levent Cerit2 Dokuz Eylül University,1 Izmir, Turquia; Near East University,2 Nicosia, Chipre; Afyon Kocatepe University School of Medicine,3 Afyonkarahisar, Turquia; Ataturk Training and Research Hospital Department of Cardiology,4 Izmir – Turquia


Introduction
Aortic valve replacement (AVR) is an established treatment modality in patients with severe symptomatic aortic stenosis (AS). 1,2Given the increased mortality and morbidity of AVR for the high-risk patients and the poor long-term results of balloon aortic valvuloplasty, transcatheter aortic valve implantation (TAVI) is increasingly accepted treatment option who are not candidates for AVR. 3 We describe here a case of succesfully implanted Edwards SAPIEN XT transcatheter heart valve without aortography guidance due to multiple arterial access problems and complicated by iatrogenic De Bakey type III aortic dissection and severe paravalvular leak.

Case report
A 79-year-old woman was admitted with dyspnea (NYHA III) over a period of 3 months.She had a history of hypertension, diabetes mellitus, hyperlipidemia and chronic renal failure.A grade 3/6 systolic murmur was heard over the aortic area.Rhythm was sinus and electrocardiography fulfilled the criteria of left ventricular hypertrophy.Transthoracic echocardiography showed a severely calcified aortic stenosis with valve area of 0.6 cm 2 , maximum gradient of 92 mmHg, mean gradient of 55 mmHg, left ventricular ejection fraction of 60%, aortic annular diameter of 20 mm, and ascending aorta of 35 mm.
Patient was evaluated by a heart team and deemed to be high risk for AVR (STS:12, euroscore:21) and accordingly decided to proceed to TAVI.Coronary angiography demonstrated the stenosis of LAD by 40%, first diagonal 40%, circumflex 85%, and proximal right coronary artery 50%.A mild to moderate aortic regurgitation was detected by aortography.The distance between left main coronary ostium (LMC) and aortic annulus was 11 mm.Right iliac artery was severly tortuous and no stenotic lesion was detected (Figure 1A, 1B).
We aimed to revascularize critical circumflex lesion before the procedure and percutaneous coronary intervention was performed.One month later, TAVI procedure scheduled.Under general anesthesia a left femoral cutdown was performed because of the severly tortuous right iliac artery.A pacemaker was placed from the right femoral vein.However, left Amplatz catheter over a Terumo and Exchange stiff wire was not got through to arcus aorta and an attemt to cross the aortic valve failed.Accordingly we noticed that the catheter was in the false aortic lumen extending from just below the left subclavian artery (Figure 1C).Soon after, catheter was completely removed and than left femoral artery repaired surgically.We were able to advance the pig-tail catheter to the ascending aorta to show the dissection by aortography via right femoral artery albeit severe tortuosity (Figure 1B, 1D).We decided to perform the TAVI procedure via right femoral artery despite of severe tortuosity.A pig-tail catheter, which is used to guide for the appropriate positioning of the prosthetic valve into aortic annulus thanks to aortography, couldn't moved due to bilateral severe brachial and subclavian artery tortuosity.Upon this, left main ostium and aortic annulus marked by a coloured pen on angiography screen accompanied by rapid ventricular pacing (Figure 2A).Immediately after, X-ray tube's angle and the patient left fixed positon, and prosthetic valve was started to implant without aortography.A 23 mm Edwards SAPIEN XT prosthetic aortic valve was deployed with rapid pacing at 180 bpm in accordance with this index drawings without aortography guidance (Figure 2B).But, aortogram following implantation showed severe paravalvular aortic regurgitation (Figure 2C).In order to solve this problem, prosthetic valve was crossed with AL-1 catheter and a straight and stiff wire, and successfully dilated with a 23 mm aortic balloon.Severe aortic regurgitation decreased to mild degree (Figure 2D).Transthorasic echocardiography obtained one day after the procedure revealed a dramatic decrease in aortic valve gradient (20/10 mmHg) and no aortic regurgitation.The patient was discharged from hospital on 6th postoperative day without any complication.

Discussion
TAVI is increasingly becoming an accepted option in the treatment of patients with severe symtomatic AS who are not eligible for surgery due to prohibitive risks and frailtiy. 4Although TAVI is less invasive than conventional open heart surgery, it has several complications including the occlusion of coronary ostia, annular rupture, ventricular perforation, paravalvular regürgitation, heart block, device malposition or embolisation, stroke, major bleeding, vascular injury, and acute kidney injury. 4is case report highlightes how to cope with multiple complications during TAVI procedure.Dissection or perforation of the ilio-femoral arteries might occur in the presence of traumatic sheath insertion. 5Dissection of the ascending or descending aorta might similarly occur due to catheter trauma or as an unpredictable complication of aortic valvuloplasty. 6onocclusive retrograde dissections commonly heal once antegrade flow is restored; therefore limited dissections are often best managed conservatively as in our case. 5Another issue is to place the valve into appropriate position.Due to arterial access problems we had to use only right femoral artery and we had no extra arterial access for aortography in order to show LMC ostium and aortic annulus.Upon this, first we Case Report marked the LMC ostium and aortic anulus on screen by a colourful pen during aortography accompanying with rapid pacing, then patient and X-ray tube fixed, and immediately after, the prosthesis valve implanted in accordance with this index drawing without aortography guidance.Another possible option could further define the annulus (landing zone) is to perform balloon aortic valvuloplasty (pre-dilatation) and to mark in the screen the waist and use it as a marker.
Mild or moderate aortic regurgitation can be seen after implantation.However hemodynamically severe postprocedural aortic regurgitation is rare. 4These are generally caused by inadequate inflation of the balloon or by calcium deposits that prevent the valve unit to properly seat and seal within the annulus. 3,7,8Severe paravalvular leak assuming incomplet expansion of prosthetic valve was declined dramatically after balloon dilatation in our patient.Also in case of thoracoabdominal dissection a different second approach (transapical or transaortic) could be suggested.These approaches give the possibility to do the procedure with pig tail on the right femoral artery and more important avoid any contact with the new dissected fragile thoracoabdominal aorta/aortic arch and Novaflex system.Additionally, transesophageal echocardiography could have been used to position the valve.
In conclusion, this case demonstrates that maybe safe to implant percutaneous aortic valve with a single fixed contrast fluoro image after an acute major vascular complication occurred, and transradial approach is an important option during TAVI procedures and can also reduce the bleeding risks as a secondary vascular access site.

Figure 2 -
Figure 2 -Deployment of prosthetic aortic valve based on index drawings (A, B), severe paravalvular aortic regurgitation following implantation (C), and aortogram showing mild regurgitation just after aortic balloon dilatation (D).