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Sumario Vol. 43 - Nº 1 Enero - Marzo 2014

Percutaneous transcatheter implantation of
aortic valve in older people

José A. Le Favi, Antonio Scutteri, Luis J. Tapia, Edmundo Falú

Cordis SA. Hemodinamia. Sanatorio El Carmen, España 1067
(4400) Salta, Argentina
E mail 1 / E mail 2

Recibido 28-NOV-13 – ACEPTADO después de revisión 17-ENERO-2013.

The authors declare not having a conflict of interest.

Rev Fed Arg Cardiol. 2014; 43(1): 42-44


Print version Imprimir sólo la columna central

 

 

SUMMARY

Percutaneous implantable prosthetic heart valve has become an important area ofinterest.Valve replacement has been declined for very high risk patients.Nonsurgical implantation of a prosthetic heart valve can be an important therapeutic alternative for the treatment of selected patients with nonsurgical aortic stenosis,with successachieved with immediate and midterm hemodynamic and clinical improvement. We present 2 case reports with severe aortic stenosis in elderly people in very high risk conditions.

Key words: Severe aortic stenosis. High risk patients. Percutaneous implantable prosthetic heart valve.

 

 

The first percutaneous aortic valve implantation (PAVI) was conducted in 2002 [1]; which was followed by a series of registries [2], that showed that this new modality to treat inoperable patients, or those in a significant risk to undergo aortic valve replacement (AVR) surgery, was feasible.

The implantation of a transcatheter aortic valve may cause an initial and sustained functional improvement, the late results of which are mainly determined by co-morbidities not related to aortic valve disease [3].

The prospective, randomized PARTNER I study [4,5], showed that the survival of patients with PAVI (Edwards Sapient TVH valve) was similar to the survival of those that underwent AVR, with a high surgical risk, not candidates to a traditional valve replacement, with absolute reduction in mortality of 20%.

 

CASE I
Female, 81-year-old patient, carrier of severe aortic stenosis, who underwent valvuloplasty by refractory heart failure 4 months before being admitted for the PAVI on March 21, 2013. She was admitted in functional class III, blood pressure 130/70, ECG with sinus rhythm, heart rate 76 bpm, PR 160 ms and CLBBB. Lab: red blood cells 3,500,000, hematocrit 32%, white blood cells 5600 (64/0/0/30/6), glycemia 141 mg/dl, urea 64 mg%, creatinine 0.8 mg%, sodium: 128 mEq/l, potassium 4.1 mEq/l, prothrombin time 18 sec (58%), INR 1.5 and platelets 179,000. Gases in blood: PH 7.49, PCO2 22.5, CO3H 16.8, base excess 6.3, Hb saturation 98%.

Pre-implant echocardiogram: severe aortic valve stenosis, with peak gradient 81 mmHg and mean gradient 58 mmHg, area 0.6 cm2, aortic annulus 21 mm, aortic root 25 mm, ascending aorta 35 mm, EF 40%; normal pulmonary pressures, global hypokinesis. Euro Score 7.53%; Surgery Thoracic Score 2.4%.

PAVI: Medtronic Core Valve of 26 mm (Figure 1).

Figure 1. Valvuloplasty with balloon. Transesophageal guide for prosthetic release

 

Post-implant echocardiogram: peak gradient 9 mmHg, mean gradient 4 mmHg, mild to moderate peri-prosthetic aortic valve insufficiency (Figure 2). Maximal blood pressure 60 mmHg, central venous pressure 15 cm H2O Hb saturation 92%. ECG: 3rd degree AV block. Treatment: PPM implant, enalapril 10 mg/day, aspirin 100 mg/day, clopidrogel 75 mg/day, cephalothin 1 gr/6 h. Hospital discharge without symptoms, with PPM on the tenth day of admittance.

Figure 2. Transesophageal echocardiogram – immediate post-implantation mild
to moderate peri-prosthetic insufficiency

 

CASE II
Female, 84-year-old patient, carrier of severe aortic stenosis, admitted in functional class III, blood pressure 110/70; ECG: with sinus rhythm, heart rate 70 bpm, PR 120 ms, and LVH. Lab: red blood cells 2,700,000, white blood cells 4600 (76/0/0/15/9), urea 84 mg%, creatinine 1.1 mg%, Na: 132 mEq/l, K 5.1 mEq/l, prothrombin time 17 sec (64%), INR 1.4 and platelets 140,000. Gases in blood: PH 7.31, PCO2 35, PO2 88, CO3H 17.2, base excess 7.6, Hb saturation 96%.

re-implant echocardiogram: severe aortic valve stenosis, with peak gradient 79 mmHg and mean gradient 44 mmHg, area 0.9 cm2, aortic annulus 23 mm, aortic root 27 mm, ascending aorta 35 mm, EF 55%; normal pulmonary pressures. Euro Score 4.77%; Surgery Thoracic Score 3.3%.

In Figures 3 and 4, angiogram showing prosthesis release and final aortogram.

Figure 3. Prosthesis release

 

Figure 4. Final aortogram

PAVI: Medtronic Core Valve of 26 mm. Post-implant echocardiogram: peak gradient 7 mmHg, mean gradient 3 mmHg. Maximal blood pressure 60 mmHg, central venous pressure 12 cm H2O Hb saturation 93%. ECG: sinus rhythm, PR 160 ms, LBBB. Treatment: aspirin 100 mg, clopidrogel 75 mg/day, cephalothin 1 gr/6 h, iron and vitamin B complex. Hospital discharge, being asymptomatic at the fourth day of admittance. In Figure 5, post-implant control with cardiac Doppler echo.

Figure 5. Cardiac Doppler echo: post-implant control.

 

 

CONCLUSIONS
In the two clinical cases of severe aortic stenosis in refractory heart failure presented, PAVI was performed successfully. The complications were according to what is mentioned in literature, complete AVB in one case, and peri-prosthetic aortic valve insufficiency in the other. Twelve years after the first PAVI, the results in the short term of the PARTNER study [4], and those in the long term for the European/Canadian Registry show a significant reduction in mortality, when compared to medical treatment and results not below those of AVR in patients in high risk [6,7].

Technical advancements and the learning curve of the operators will further reduce in a near future, the complications related to the procedure and may make of PAVI a therapeutic alternative to aortic valve replacement, even in younger individuals and those with a low to moderate risk with severe, calcified and symptomatic aortic valve stenosis.

 

BIBLIOGRAPHY

  1. Cribier A, EltchaninoffH, Bash A, et al. Percutaneous transcatheter implantation of aortic valve prosthesis for calcific aortic stenosis, first human case description. Circulation 2002, 106: 3006-8.
  2. Beckmann A, Hamm C, Figulla HR, et al. The German aortic valve registry (GARY): a nationwide registry for patients undergoing invasive therapy for severe aortic valve stenosis. ThoracCardiovascSurg 2012;60:319-25.
  3. Webb JG, Altwegg L, Boone RH, et al. Transcatheter aortic valve implantation: impact on clinical and valve related. Circulation 2009; 119: 3009-16.
  4. Craig RS, Leon MB,Mack MJ, et al. for the PARTNER Trial Investigators Transcatheter versus surgical aortic-valve replacement in high-risk patients.N Engl J Med 2011;364 (23): 2187-2198.
  5. Kodali SK,Williams MR, Smith CR, et al. for the PARTNER Trial Investigators. Two-year outcomes after transcatheter or surgical aortica valve replacement. N Engl J Med 2012;366:1686-95.
  6. Bonow RO, Carabello BA, Chatterjee K, et al. 2008 focused update incorporated into the ACC/AHA 2006 Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients withvalvular heart disease).Endorsed by the Society of Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.J Am CollCardiol 2008;52:el-142.
  7. Gossl M, Holmes DH. An Update on transcatheteraortic valve replacement. CurrProblCardiol2013;38(7):245-83.

 

Publication: March 2014

 
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