Transapical Aortic Valve Implantation in a Patient With Severe Aortic Stenosis and Pott Disease
A 72-year-old woman was admitted to our hospital with the diagnosis of pulmonary edema. She had a history of Pott disease since childhood and presented with extremely severe kyphoscoliosis and thorax deformation (Figures 1 and 2⇓) leading to a severe restrictive pulmonary syndrome requiring domiciliary oxygen therapy. ECG showed sinus rhythm and left ventricular hypertrophy (Figure 3). Doppler echocardiography demonstrated severe calcific aortic stenosis (Movie I in the online-only Data Supplement), with a mean gradient of 64 mm Hg, aortic valve area of 0.50 cm2, and left ventricular ejection fraction of 74%. Coronary angiography showed the absence of coronary artery disease. The patient was considered unsuitable for conventional surgical aortic valve replacement because of her severe thorax deformation and pulmonary disease, and she was then evaluated for transcatheter aortic valve implantation technique.1 Three-dimensional computed tomography showed an extreme thoracic aorta tortuosity (Figure 4), precluding a retrograde approach through the femoral artery, and transapical aortic valve implantation was then proposed.
The procedure was performed in the operating room under transesophageal echocardiography and fluoroscopy guidance by a team of cardiac surgeons and interventional cardiologists using the techniques described in previous reports.2–4 Briefly, a left anterior minithoracotomy was performed to expose the apex, and 2 large purse strings with pledgets were placed at the left ventricular apex. An aortic angiography was performed just before the ventricular apex was punctured (Movie II in the online-only Data Supplement). After the apex was punctured, a 26F-sheath was inserted into the left ventricle over a wire, and an aortic balloon valvuloplasty was performed under rapid pacing (Movie III in the online-only Data Supplement). On the basis of an aortic annulus measurement of 19 mm by transesophageal echocardiography, a 23-mm Edwards SAPIEN valve (Edwards Lifesciences Inc, Irvine, Calif) was selected for implantation. Valve positioning was performed under transesophageal echocardiography and angiography guidance (Figure 5A and Movies IV and V in the online-only Data Supplement); valve deployment was performed under rapid pacing (Figure 5B and Movie VI in the online-only Data Supplement). After valve implantation, fluoroscopy, transesophageal echocardiography, and aortography showed the appropriate position of the prosthesis (Figure 5C and Movies VII and VIII in the online-only Data Supplement), and Doppler echocardiography evidenced a mean residual aortic gradient and aortic valve area of 10 mm Hg and 1.8 cm2, respectively, with the presence of trivial paravalvular aortic regurgitation and mild mitral regurgitation (Movie IX in the online-only Data Supplement).
The postoperative period was complicated by nosocomial pneumonia and surgical wound infection, but the patient was finally discharged at home in good condition. At 6-month follow-up, the patient was in New York Heart Association functional class II, and chest x-ray showed correct position of the valve (Figure 6). Doppler echocardiography showed the absence of hemodynamic changes compared with the data obtained before hospital discharge (Movies X and XI in the online-only Data Supplement).
Pott disease is a tubercular spinal infection that primarily affects the body of the thoracic and lumbar vertebrae, leading to severe spinal deformity if delay in diagnosis and treatment occurs. To the best of our knowledge, no cases of cardiac surgery in patients with Pott disease have been reported previously. Such patients are at highest risk, and frequently conventional surgical aortic valve replacement is precluded. Furthermore, the frequent association of severe thoracic aorta deformity can preclude the use of transfemoral valve implantation, and therefore transapical aortic valve implantation may represent the only alternative for the treatment of severe aortic stenosis in such patients. The present report shows the feasibility of transapical aortic valve implantation in a patient with an extremely severe thoracic deformation, opening a new avenue for the treatment of such highly challenging patients.
The authors want to thank Stéphane Morin, MSc, for his technical assistance in the preparation of images and movies.
Drs Dumont and Rodés-Cabau are consultants for Edwards Lifesciences Inc. Dr Pibarot received honoraria from Edwards Lifesciences Inc. The remaining authors report no conflicts.
The online-only Data Supplement is available with this article at http://circ.ahajournals.org/cgi/content/full/120/16/e140/DC1.
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