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Table of Contents
CASE REPORT
Year : 2018  |  Volume : 1  |  Issue : 2  |  Page : 158-160

Transcatheter aortic valve replacement in rheumatic aortic stenosis


1 Department of Cardiology, Apollo Hospitals, Chennai, Tamil Nadu, India
2 Department of Pediatric Cardiology, Apollo Hospitals, Chennai, Tamil Nadu, India
3 Department of Cardiothoracic Surgery, Apollo Hospitals, Chennai, Tamil Nadu, India
4 Department of Anaesthesia, Apollo Hospitals, Chennai, Tamil Nadu, India

Date of Web Publication13-Dec-2018

Correspondence Address:
Dr. Sengottuvelu Gunasekaran
Department of Cardiology, Apollo Hospitals, Greams Road, Chennai 600006, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IHJI.IHJI_21_18

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  Abstract 

Transcatheter aortic valve implantation (TAVI) is a rapidly evolving therapeutic option for patients with severe aortic stenosis (AS) who are at a high risk for surgery or inoperable. The data on the use of TAVI in rheumatic AS are not widely available and have not been reported from India. We present a case report of TAVI in rheumatic AS and prior mitral valve replacement with multiple comorbidities.

Keywords: Rheumatic aortic stenosis, rheumatic etiology, transcatheter aortic valve implantation


How to cite this article:
Gunasekaran S, Chinnasamy Sivaprakasam M, Sadhasivam V, Arumugam GC, PaulPandi VK. Transcatheter aortic valve replacement in rheumatic aortic stenosis. Indian Heart J Interv 2018;1:158-60

How to cite this URL:
Gunasekaran S, Chinnasamy Sivaprakasam M, Sadhasivam V, Arumugam GC, PaulPandi VK. Transcatheter aortic valve replacement in rheumatic aortic stenosis. Indian Heart J Interv [serial online] 2018 [cited 2019 May 22];1:158-60. Available from: http://www.ihji.org/text.asp?2018/1/2/158/247445




  Introduction Top


Transcatheter aortic valve implantation (TAVI) is a rapidly evolving therapeutic option for patients with severe aortic stenosis (AS) who are at a high risk for surgery or inoperable.[1] Recently it has been approved for use in intermediate risk patients. The data on the use of TAVI in rheumatic AS are not widely available and have not been reported from India.

Pathology in rheumatic AS differs from calcific severe AS[2] and is characterized by commissural fusion with restricted opening and no calcification. We present a case report of TAVI in rheumatic AS and prior mitral valve replacement (MVR) with multiple comorbidities.


  Case Report Top


Mr. X, a 55-year-old man, who is a known case of rheumatic heart disease, underwent closed mitral commissurotomy for severe mitral stenosis (1984) and subsequently in 2009 he underwent MVR with mechanical valve (St. Jude Medical, Minnesota, United States of America). He did not have any recognized aortic valve disease at the time of MVR. He also had chronic atrial fibrillation, type 2 diabetes mellitus on insulin, chronic kidney disease, and dyslipidemia. His society of thoracic surgery (STS) score for surgical aortic valve replacement (AVR) was 8.2%. His STS score was 8.2 due to his post-MVR status, diabetes requiring insulin, atrial fibrillation, recent heart failure admission, and chronic kidney disease. He was diagnosed to have significant mixed aortic valve disease, moderate AS, and moderate aortic regurgitation. He was symptomatic with recurrent episodes of heart failure and presently in New York heart association class II–III. After heart team discussion, it was decided to proceed with AVR as he had symptomatic severe mixed aortic valve disease. Echocardiographic evaluation showed severe left ventricular hypertrophy, disproportionate to hypertension and declining left ventricular systolic function with ejection fraction of 50%. The aortic valve was thickened with commissural fusion and had minimal calcification. Although TAVI is usually indicated for degenerative AS and not for rheumatic AS, it was considered as an alternative in this case because of very high surgical risk. Computed tomography evaluation showed tricuspid aortic leaflets, annulus diameter of 22.7mm, and coronary heights of 18.3mm on the right side and 13.3mm on the left side. His epicardial coronaries had insignificant coronary artery disease with adequately sized iliofemoral arteries. He was considered for transfemoral TAVI.

Balloon aortic valvuloplasty and simultaneous aortogram were carried out to assess annular size and rule out coronary occlusion. Balloon expandable SAPIEN 3 (Edwards lifesciences, California, United States of America), size 23-mm valve was meticulously positioned and slowly deployed during rapid ventricular pacing to achieve precise positioning. We achieved satisfactory hemodynamics, and final aortogram showed no paravalvular leak [Figure 1], [Figure 2], [Figure 3]. He was discharged in a stable condition the next day.
Figure 1: Distance between the aortic valve annulus (arrow) and mitral prosthetic valve (arrow head) was 8mm

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Figure 2: Post TAVI, the distance between aortic prosthetic valve (arrow) and mitral prosthetic valve (arrow head) was 3mm

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Figure 3: Final cine angiographic image after TAVI

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  Discussion Top


The use of TAVI as a therapeutic strategy is considered as a relative contraindication in rheumatic AS.[3] The presence of annular/leaflet calcium is very essential for performing TAVI as it helps to anchor the valve and prevent valve embolization. Our case was unique with extreme high risk, and anticipated challenges were minimal calcification and the presence of functioning mitral prosthesis, all of which increased the risk of valve embolization and coronary occlusion.

Recent reports have shown that approximately 1 in 10 patients in the US have TAVI for an off-label indication, especially aortic or mitral regurgitation and bicuspid aortic valves. In multivariate analysis, 1-year mortality was no different in patients who had TAVI for an off-label condition relative to those who had transcatheter AVR for an on-label indication.[4] Apart from degenerative AS, other expanded indications include patients with patent coronary bypass grafts, especially functioning internal thoracic arteries; failed aortic bioprosthesis, at least 23mm in size, avoiding re-sternotomies for cardiac reoperation; and patients with contraindications for sternotomy (e.g., retrosternal esophageal conduits).

As transcatheter valve requires annular/leaflet calcification to anchor, in this case, adequate calcium was available for holding the valve, which was evident during balloon dilatation. Regarding the choice of the valve, both self-expanding versus balloon expandable were considered. Even though the Medtronic Evolut R valve has the advantage of the ability to recapture and reposition even when upto 80% of the valve is deployed, it needs to be implanted in deeper position relative to other valves, which might not only interfere with the mitral prosthesis but also potentially cause displacement toward the aorta and lead to inadequate positioning. SAPIEN 3 valve was chosen considering the lesser possibility of its interference with the mitral prosthesis. Coronary occlusion was not a major concern because of the absence of bulky leaflet calcium and also the visualization of patent coronaries during the simultaneous aortogram conducted along with balloon valvuloplasty.

SAPIEN 3 valve, in view of its non-repositionable characteristics, should be precisely positioned in the aortic annulus with adequate pacing and slow deployment of the valve, which are critical to assure stable implantation. Although device embolization usually occurs early, it may even occur later, and hence, a stringent follow-up is necessary.

Finally, this is a good prelude to start clinical trials for rheumatic AS, especially in the developing countries, where we still see several patients with rheumatic valvular heart disease.


  Conclusion Top


TAVI can be performed in patients with rheumatic AS, who are not candidates for surgery, after meticulous planning. The presence of minimal annular calcium and/or slight oversizing the valve size might help to anchor the valve. In the presence of functioning mitral prosthesis, adequate pacing, meticulous positioning, and slow deployment are crucial to ensure that the valve is not too deep to avoid mitral paravalvular leak.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kodali SK, Williams MR, Smith CR, Svensson LG, Webb JG, Makkar RR, et al.; PARTNER Trial Investigators. Two-year outcomes after transcatheter or surgical aortic-valve replacement. N Engl J Med 2012;1:1686-95.  Back to cited text no. 1
    
2.
Mehmet B, Ayse SY, Recai A, Sina A. Transcatheter aortic valve implantation with the CoreValve for the treatment of rheumatic aortic stenosis. Anatol J Cardiol 2014;1:296-7.  Back to cited text no. 2
    
3.
Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Barón-Esquivias G, Baumgartner H, et al.; Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC); European Association for Cardio-Thoracic Surgery (EACTS). Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 2012;1:2451-96.  Back to cited text no. 3
    
4.
Hira RS, Vemulapalli S, Li Z, McCabe JM, Rumsfeld JS, Kapadia SR, et al. Trends and outcomes of off-label use of transcatheter aortic valve replacement: Insights from the NCDR STS/ACC TVT Registry. JAMA Cardiol 2017;1:846-54.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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Abstract
Introduction
Case Report
Discussion
Conclusion
References
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