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Hsin-Bang Leu, Hsiao-Huang Chang, Su-Man Lin, Ying-Hwa Chen, Double trouble for transcatheter aortic valve implantation: a patient with no vascular access and high-risk features for bilateral coronary obstruction, European Heart Journal, Volume 38, Issue 36, 21 September 2017, Page 2787, https://doi.org/10.1093/eurheartj/ehw083
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Extract
A 69-year-old female with a history of hypertension and coronary artery disease presented with progressive exertional dyspnoea. Echocardiography revealed severe aortic stenosis with a mean aortic pressure gradient of 61 mmHg and an aortic valve area of 0.6 cm2. Surgical aortic valve replacement was aborted due to an unexpected porcelain aorta identified during exploratory pericardiotomy and transcatheter aortic valve replacement (TAVR) was considered. Extensive horseshoe calcifications and small diameters (from 4.2 to 5.6 mm) of the bilateral iliofemoral arteries and small left subclavian artery diameter (5.3 mm) precluded the transfemoral and trans-subclavian access. A direct aortic approach was prohibited due to the porcelain aorta. The right and left carotid arteries measured 6.6 and 6.8 mm, respectively, smaller than the 7.5 mm recommended for transcarotid access. Thus, all conventional vascular access methods were not feasible. Furthermore, the patient had low-lying ostia of both coronary arteries (8.5 mm for the left coronary artery and 8.4 mm for the right coronary artery) (Panels C and D), and shallow sinus of Valsalva (diameter 24.1 × 27.3 mm). Both are risk factors for coronary obstruction. Transapical access with an Edwards Sapien XT valve was considered, but given a nearly 2.4-fold higher risk of coronary obstruction than a self-expanding one. By examining reconstructed CT images, a segment of the distal abdominal aorta free of calcifications just below the bilateral renal arteries was identified, suggesting a possible option for the entry site (Panel A). Therefore, we decided to deliver a self-expanding Medtronic Corevalve using the abdominal aorta for vascular access. Laparotomy was performed through a midline incision, and the omentum and bowels were protected and packed away from the surgical field. The distal abdominal aorta was gently palpated to identify an area free of calcifications. The aorta was punctured and the 18-Fr sheath was inserted through the abdominal aorta into the descending ascending aorta.
