Author + information
- Received July 1, 2013
- Accepted July 3, 2013
- Published online April 1, 2014.
- Cara Hendry, MBChB, MD∗ (, )
- Anthony Della Siega, MD,
- Imad J. Nadra, MBChB, BSc, PhD and
- Simon D. Robinson, MBChB, BSc, MD
- ↵∗Reprint requests and correspondence:
Dr. Cara Hendry, Victoria Heart Institute Foundation, 200-1900 Richmond Road, Victoria, British Columbia V8R 4R2, Canada.
Transcatheter aortic valve replacement (TAVR) is increasingly being used to treat patients with severe aortic stenosis who are either deemed to be inoperable or at prohibitive surgical risk (1). Both operator experience and devices have evolved over time, as have the indications for valve implantation.
We present the case of a 92-year-old woman with symptomatic aortic stenosis (area, 0.7 cm2; peak/mean gradients, 45/24 mm Hg, respectively; ejection fraction, 55%), stable coronary artery disease, hypertension, and peripheral vascular disease who was deemed to be inoperable due to the presence of a porcelain aorta.
She was also known to have an aneurysm of the sinus of Valsalva limited to the right coronary cusp that was detected on transthoracic echocardiography (Fig. 1). This finding was confirmed by aortography (Fig. 2) and computed tomography (CT) (Fig. 3).
The presence of a sinus of Valsalva aneurysm, although not a contraindication to TAVR, could conceivably increase the risk of aortic rupture, a rare, but potentially devastating complication (2,3), during pre-dilation or valve deployment. We elected therefore to implant a self-expandable Medtronic CoreValve to minimize this risk (because it does not require balloon inflation to deploy the valve), while performing only modest pre-dilation with an 18-mm NuCLEUS balloon (NuMed Canada, Inc., Cornwall, Ontario, Canada). A 26-mm Medtronic CoreValve (Minneapolis, Minnesota) (based on CT dimensions) was then deployed safely under rapid pacing, and the subsequent aortogram (Fig. 4) showed the valve to be well deployed, with reduced filling of the aneurysm. This was later confirmed by CT scan (Fig. 5).
This case demonstrates that inoperable patients with aortic stenosis and a concomitant sinus of Valsalva aneurysm may be treated safely in selected situations by TAVR with a self-expandable transcatheter valve.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received July 1, 2013.
- Accepted July 3, 2013.
- American College of Cardiology Foundation
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