In this case study, interventional cardiologist Dr. Matthew Summers presents the management of a high-risk patient with a prior history of surgical aortic valve replacement (SAVR). The patient now presents with a significantly reduced ejection fraction and is deemed high risk for repeat surgery. The case highlights the rationale, planning, and execution of a transcatheter aortic valve replacement (TAVR) procedure as a less invasive alternative. Designed for a clinical audience, this video offers insights into decision-making, procedural nuances, and outcomes in complex structural heart disease interventions.
Hi, this is Matt Summers. I'm the program director of structural art at Centerra Norfolk General, uh, and at the Centerra Heart Valve Center. Um, I'm presenting a case that came in, uh, to our hospital in March, um, and, uh, highlights some interesting points, uh, regarding advanced therapies and valve disease patients, especially when they present in extremists, um, and with, uh, some unusual findings, uh, that can sometimes limit. Our capabilities and so uh this highlighted a multidisciplinary approach uh for taking care of a very sick uh patient with prior sternotomy from. Uh, polyvalvular surgery. And so this is a 58 year old female that we had known previously within our system. Um, she underwent a surgical aortic valve replacement in 2011 with a 19 millimeter magnet Ee valve, and it was an ascending repair with a Valsalva graft, jellweave Valsalva graft, um, and it come in uh in February of this past year with a demonstrated normal ejection fraction. Um, but with critical bioprosthetic aortic stenosis, and so at the end of January she had had an elective outpatient echocardiogram that showed a peak velocity of 4.8 m per second across her bioprosthetic valve, meaning gradient of 57 with a DI 0.13 at that time her EF was preserved. Um, and she, uh, was seen by our surgical colleagues where we do operative, uh, surgical therapies were discussed given her young age of 58 years old, um, at the time she was uh deemed elevated but not prohibitive risk or or increased risk because of um her normal ejection fraction and with the consideration towards lifetime management, there was some plans uh to do. A redo uh open heart surgery with a larger valve. It's of note that um her BMI was 30 and so a 19 millimeter valve, uh, very likely did have some component of patient prosthesis mismatch in reviewing her echocardiograms in sequence since 2011, um, she had had uh elevated gradients in the, in the high teens, but it wasn't until this past uh year at her one year follow up that we had seen the gradients increase to the the level that they are. Uh, at the end of January and so. She had this workup ongoing and and came back in actually in extremists uh about a month later while she was undergoing outpatient evaluation or expedited outpatient evaluation, um, she had a new ejection fraction of 15% presented with hypoxemic respiratory failure requiring BiPAP, uh, and then high flow nasal cannula. She had initially end organ uh function that was stable with normal blood counts, creatinine, um, she, uh, had normal urine output and at least initially. On steadied out with medical therapy, um, but did have uh a rise in her lactate to 3.7 and some alleguria develop uh shortly after initial medical stabilization. She was able to be, uh, worked up, uh, in the outpatient setting with this CT scan that demonstrated the anatomic feasibility of a valve and valve taver, uh, as well as some of the limitations and issues in her, uh, proximal ascending. Um, and down towards the root where she had this prior stronotomy, um, this was a, uh, 19 millimeter valve, and so it would require either a 20 or 23 sapien versus a 23 evolute, and the plan would obviously be under controlled situations to to give her the best hemodynamic, uh, performing valve with the valve and valve, but we're also, uh, at this point in time with her presentation now with an EF of between 15 and 20%. Um, but with still a peak velocity of 4.6 m per second, I mean gradient of 50 across the valve in spite of her uh low output. She had good ileofemoral axis for taver. Some of her risk scores, at least when she was coming in, uh, with a normal EF were reasonable, um, but after she came in, uh, obviously in extremis, um, this, this, uh, presentation changed quite a bit. So when we looked through her uh presentation initially, um, again, she came into the, the CICU with hypoxemic respiratory failure. You can see we now have an overt contraindication uh to taver, which is a large mobile LV thrombus that developed in the interval 1 month, um, she was at this point in time on 10 of dibutamine, 5 of epinephrine, and 10 mics of norepinephrine. Uh, with a lactate that was increasing and with alleguric renal failure. She had no, uh, transaminitis or anything uh else as far as end organ dysfunction, but, um. Clearly was sick and needed a decision to be made about her valve uh therapies. Uh, we convened with our advanced heart failure therapies and and what's called a shock call. We convened with that team and our surgical colleagues um about re-operative risk. They thought it would be a long clamped time and that she was in extremists and cardiogenic shock going into this, um, that, uh, it was prohibitive risk. Now if we could exhaust everything we could do with valve and valve to have her, we should do that. Obviously with valve and valve Taver we had uh an LV thrombus that was uh gonna be at a very, very high increased cardio thromboembolic risk and from uh a standpoint of her only being 58, um, we really were hoping that she would be an advanced surgical option candidate with um reduced surgery and and potentially a transplant, uh, but bridging her uh until then with either mechanical support that she would need. Was limited by the presence of the LB thrombus, um, and there was a significant lack of uh. Uh, concerns, um, alleviated by our advanced heart failure, uh, folks as far as her candidacy for advanced surgical options even at 58. And so with those two things in mind, we, we had a 58 year old female with a cardiogenic shock and critical bioprosthetic aortic stenosis, um, on rising pressors, two ionotropes that has an LV thrombus that doesn't have surgical options and also doesn't have advanced surgical options like LVAD or transplant. As is the case with most valve and valve interventions and anything of complexity, uh, in our valve center we did advanced pre-procedural computational modeling and simulations. um, this was, uh, based on her CT scan. You can see the sino tubular junction junction calcification. Um, and its proximity, um, to the prior gel weave graft. This is simulations done with two different valve platforms, um, the BE's balloon expandable, so a 20 sapien, a 20 sapient with valve fracture, which we would intend to do given the component of uh. Patient prosthesis mismatch, a 23 uh sapien, or a 23 evolute, um, the coronary analysis shows that we are unlikely to have any coronary issues with any of the valve platforms. You can see here that with a 20 S3, we have expansion, plenty of room in the sinuses. With a 20 with valve fracture, you can see they really demonstrating remodeling of the the surgical struts. The fracture is a little bit more difficult to uh predict, but we still have plenty of room in the sinuses, so coronary sequestration and coronary occlusion are less of an issue. This is with the 23 blue and expandable valve. This is looking into the coronary, so the left corner of the 20 is is wide open, no coronary risk. Same with the right, same with the valve fracture. Same with the 23, both left and right, and then with our self-expanding bowel, which would be our preference if we had uh this under elective circumstances, um, shows that we've got capacious sinuses and really are not at risk for having coronary collusion. This demonstrates the necessary uh component of comital alignment with our new valve, um, you can see that our old valve, of course, has comital alignment, but the only uh concerns here are just the sound of tubular junction calcification. Uh, and we had to, to, to make sure that we were aligned, uh, with the, the tabracomishures, um, which is why we ultimately went with an Evolute FX plus. And so we were forced into a scenario where she had no other options, was clearly uh going to pass away in hours or days with, with this problem, and uh we didn't have surgical options, albeit advanced heart failure or surgical options, um, and we didn't have radiostriotomy as an option, so ultimately we, we elected after multiple discussions to treat this patient, um, in the intervening 12 hours while we continued to. Have uh medical stabilization with fibertolysis and we treated it uh as per protocol with left sided mechanical valve thrombosis. So in our, in our mind, we viewed this as a similar situation where a patient with left sided mechanical valves comes in with valve thrombosis, um, and are not surgical candidates. There are protocols established for giving lytics in those settings, uh, and to monitoring results and so obviously the concern with the valve and valve tab, particularly of the valve that's seized. Is that uh we would have to have an LV wire wire manipulation in the LV apex that would put her at extreme risk for cardio thromboembolic events. We discussed uh uh trying to debulk the thrombus medically debulk the thrombus percutaneously with aspiration thrombectomy preceding uh the procedure and with sentinel bolic protection in place, but ultimately, uh, while we were arranging all of our multiple teams and planning uh in the. Uh, really what amounted to be 18 hours since her presentation, we quickly, uh, after ruling out her surgical candidacy and advanced therapies candidacy, uh, gave her doses of, uh, fibranalytics, TPA, uh, and repeated CTs or repeated echocardiograms in 6 hours, and you can see we significantly debulked uh that thrombus. Um, after the, the, the second dose, however, she, she continued to have issues with oliguria and did have uh a hematoma in her, her right upper, uh, forearm just from a blood pressure cuff, and so we elected, uh, to proceed at that point in time with valve intervention. This is the narration of our actual procedure, so you can see um. With this, the considerations were obviously that we still had a very small amount of thrombus in the LV apex, um, that we weren't going to be able to navigate other than with catheter manipulation and doing aspiration thrombectomy, which would probably be best served doing transeptalally and through the mitral valve, uh, versus uh in addition to protecting uh all four branch vessels, and we can really only do that with centralbolic protection from, from both sides. So this is us deploying the right brachiocephalic or nominate filter, um, curling the Wire back and then wiring the left common carotid and deploying that filter. This is showing the Swangans catheter. You can see our ice catheter uh in here as well, um, and that's uh um. Image on the upper right is our ICE catheter. We use this with our cardiac imager in place to uh show us exactly how deep into the, the ventricular apex we were, um, so that we could continuously watch our wire position while we were um in the procedure. Obviously, um, TE was possible and and was something that we had planned on doing, but we could see the LVAex much better with intracardiac echo and elected to keep that uh positioned in the right uh femoral vein uh for us to look at our our LV wire during tavern. This is again a 3D ice, in this case it's just two planes with color. This is us attempting to wire the the valve, and this was actually quite difficult, one of the more difficult valves to wire, mostly because the aortic valve wasn't opening hardly at all. This patient had a gradient that you'll see of of almost 80 peak to peak, um, in spite of her cardiac index of 1.6 to 1.8 on twoinotropes. And so we struggled quite a bit to cross here and ultimately we were considering doing unicorn and electrocautery crossing, uh, but this is with glide wires, glide cats, um, this is with multiple different diagnostic catheters. Straight is usually what we typically, uh, use, and then upgrade to a straight supportive glide wire. None of those things are feasible. You can see his pacing at 90, trying to increase our systolic ejection period, and ultimately this is one of the more difficult valves we crossed. Um, and right before we were about to, uh, turn the wire around and do electrocautery, we were able to cross our catheter, uh, you can see would not traverse, and so we placed a super core wire in and then with a 40 charger peripheral wire, we had to pre-dilate the valve, um, and that was just to make a little bit of room and so this is over a super core wire and a stiff, uh. Portion of the super core wire that has a wooly tip of course for taking a floral balloon is in the ore and were inflating. And this was quite simply because uh we were worried about the trajectory of this this wire in the apex and being able to cross with our evolute. So you can see really nicely in the upper right, you can see our safari wire on uh ice and biplane. You can see every time we get close to that. Uh, LVAex. Our immature Gives us caution and uh we very carefully pull back. Now this was actually very difficult in spite of uh the pre-dilation of the oral balloon, given the prior repair. But you can see with dottering of the wire right there, we were able to cross. Ultimately, it limited our ability to be very, very precise in the depth, um, you can see right here, it's very difficult to get this to cross through. We're coming to a view that's equivalent to a cusp overlap view here, um, trying to aim for an implant of 4 millimeters. So basically the dots are at 3 millimeters. We'd like to implant at 4 per the valve and valve va and and for what we know about these magnae valves also give us room to post dilate. And do a valve fracture That shows uh right here how constrained our evolute valve is in spite of uh pre-dilating, you know, with a small balloon. And ultimate ultimately right here you can see her control pacing at 110, but her pressures are very intolerant to this 60s over 40s. PA pressures are similar to her systemic pressures. We're very constrained and so the decision at this point is, are we unfolded? Can we get away with just post dilation here? Uh, can we get this valve functioning? With a better release and that's ultimately what we did. So we felt we could get in and post dilate this and fracture this quicker and that repeated valve deployments would be uh. very difficult for her LV to tolerate. So you can see we're trying to keep that wire out of the LV apex, but given how stenotic this is, it's very difficult. You can see we'd have uh incomplete stent expansion, so we come back in with a balloon. This is a valve fracture and post dilation. This requires taking a. A Kevlar balloon up to, but the situation was 24 atmospheres. You can see how it expanded thereafter, the, the valve what's much in a much deeper position settled in, ultimately than what we had initially preferred were, were well below 4 millimeters, and that's kind of the nature of of this is that uh. We didn't have as much control over the depth of implant, uh, given her hemodynamic instability and um the inability to uh get very much wire purchase in the left ventricle with the safari wire. We take out both sentinel devices. There was particulate in both sentinel devices, but she didn't have any other embolic phenomena. You can see her blood pressure has increased almost 80 points. She was able to uh come off of, uh. Uh, her norepinephrine very quickly and we maintained her on, uh, the Epi and the dobutamine. The Epi was able to be titrated down very quickly, um, and over the subsequent 4 days that she was in the hospital, um, her hypoxemia improved rapidly. Um, she had, uh, residual gradients after the valve fracture, uh, 8 millimeters, and, um, it was able to be discharged with an ejection fraction of about 30%, uh, in the week after her, her valve and bowel patter. More importantly, she didn't have any um focal neurologic deficits or consequences of uh systemic embolic events from her non LB thrombus. So this patient is doing very, very well after emergent and quite literally salvage valve and valve, uh, tavern with a known LV thrombus. This case highlights really in, in our situation, a, a younger patient that that had no other options, uh, that had a typical contraindication for tara, which is an LV thrombus, that we're able to navigate by using what we know about. Mechanical valve thrombosis on the left side and some of the trials that have been developed and the practice patterns that have developed uh to treat those when patients aren't candidates for reduced sternotomy and apply those to a patient with critical bioprosthetic aortic stenosis who's quite literally um. Uh, actively passing away, we're able to uh offer her valve and valve tab with double cerebral robolic protection, um, as well as, uh, decreasing the thrombus burden medically through, um, fibrlysis used in an atypical fashion. Thank you.
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