Author + information
- Received May 16, 2016
- Revision received June 6, 2016
- Accepted June 20, 2016
- Published online September 26, 2016.
- Nicolas Amabile, MD, PhDa,∗ (, )
- Aurelie Veugeois, MDa,
- Jean-François Paul, MDb and
- Christophe Caussin, MDa
- aDepartment of Cardiology, Institut Mutualiste Montsouris, Paris, France
- bDepartment of Radiology, Institut Mutualiste Montsouris, Paris, France
- ↵∗Reprint requests and correspondence:
Dr. Nicolas Amabile, Institut Mutualiste Montsouris, Department of Cardiology, 42 Boulevard Jourdan, 75014 Paris, France.
An 81-year-old woman was referred to our center for severe aortic regurgitation (AR) related to bioprosthesis degeneration. She initially had an ascending aortic aneurysm with symptomatic AR and underwent surgical implantation of a Trifecta 21-mm prosthesis (St. Jude Medical, St. Paul, Minnesota), associated with supracoronary aortic replacement with a tube graft, 23 months previously. Her medical history also included recurrent paroxysmal atrial fibrillation and ischemic stroke with secondary hemorrhagic transformation. Transthoracic echocardiography showed severe AR (related to cusp fracture), preserved left ventricular function, and pulmonary hypertension. Logistic European System for Cardiac Operative Risk Evaluation score and Society of Thoracic Surgeons score were 69% and 11.5%, respectively. Computed tomography identified an ascending aortic false aneurysm (neck diameter 6 mm, maximal diameter 20 × 13 mm) at the junction between the native aorta and the tube graft (Figure 1A).
We proposed to treat this complex failed bioprosthesis with a 1-time percutaneous procedure combining false aneurysm closure and transcatheter aortic valve-in-valve implantation.
Double transfemoral arterial access was performed (8-F and 14-F). First, we selectively opacified the false aneurysm with an 8-F JR4 guiding catheter (Figure 1B, Online Video 1) and then deployed a 7-mm Amplatzer atrial septal defect occluder (ASDO; St. Jude Medical) (Figure 1C, Online Video 2). The ASDO remained initially attached to the delivery cable (Figure 1D, Online Video 3). A CoreValve Evolute-R 23-mm device (Medtronic, Minneapolis, Minnesota) was then partially deployed (Figure 1E, Online Video 4) within the failed bioprosthesis. The ASDO was then detached, and the CoreValve was finally fully deployed, which stabilized the ASDO outer disc (Online Video 5). Control angiography showed complete aneurysm closure and no residual AR (Figure 1F, Online Video 6). The final mean transprosthetic gradient was 7 mm Hg. The patient was discharged on warfarin and aspirin therapy, and the subsequent clinical evolution was uneventful.
This case illustrates the feasibility of 2 combined structural heart disease interventions during a single procedure in a patient with a complex condition and very high risk for redo surgery. This double-faced procedure evoked the traditional representation of the ancient Roman god Janus.
For supplemental videos, please see the online version of this article.
Dr. Caussin is a proctor for Medtronic. Drs. Amabile and Caussin have received consulting fees from St. Jude Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received May 16, 2016.
- Revision received June 6, 2016.
- Accepted June 20, 2016.
- American College of Cardiology Foundation