© 2013 Wiley Periodicals, Inc.
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Transfemoral Aortic Valve Replacement in Failing Aortic Root Homografts Lynda Otalvaro, M.D.,* Carlos E. Alfonso, M.D.,* William W. O’Neill, M.D.,y Brian P. O’Neill, M.D.,* and Alan W. Heldman, M.D.* *Department of Medicine, Cardiovascular Division and the Elaine and Sydney Sussman Cardiac Catheterization Laboratory, Miami, Florida; and yHenry Ford Hospital, Detroit, Michigan ABSTRACT Transcatheter aortic valve implantation (TAVI) for failing aortic root and valve homografts has been described primarily via a transapical approach. We report the successful treatment of two patients with failing homografts by transfemoral (TF) TAVI. In both cases, TF TAVI was accomplished without technical difficulty and with good clinical outcomes. doi: 10.1111/jocs.12277 (J Card Surg 2014;29:333–336)
Transcatheter aortic valve implantation (TAVI, also known as transcatheter aortic valve replacement) has emerged as a viable option for the treatment of calcific aortic stenosis in patients who are at high risk1 or ineligible for surgical aortic valve replacement (SAVR). Registry studies have also suggested that TAVI may also be a feasible approach to treat degenerated bioprosthetic aortic valves, with a valve-in-valve technique.2–6 Aortic valve and root homografts have been used for surgical treatment of the aortic valve, particularly when there is infective endocarditis. As with any bioprosthetic valve, tissue calcification or degeneration may lead to a need for replacement. Reoperation for homograft failure occurs in 10% to 25% within 15 years, and nearly 50% by 20 years.7 TAVI has been reported for treatment of homograft failure in several cases, and the use of a surgical access approach (via thoracotomy and the left ventricular apex, or sternotomy and direct aortic catheterization) has been advocated based on concerns for disrupting the friable homograft aortic root with the transfemoral method.8 We report our experience of transfemoral (TF) TAVI using the Edwards SAPIEN1 Transcatheter Heart Valve (Edwards Lifesciences, Irvine, CA, USA).
Conflict of interest: Dr. Heldman—research support, Edwards Lifesciences, Inc.; Dr. William O’Neill—research support, Edwards Lifesciences, Inc. Address for correspondence: Alan W. Heldman, M.D., University of Miami Miller School of Medicine, Clinical Research Building, 1120 NW 14th Street, Suite 1127, Miami, FL 33136. Fax: þ1-305-243-1731; e-mail: [email protected]
SURGICAL TECHNIQUE The Institutional Review Board of the University of Miami approved the reporting of these cases Patient 1 is a 52-year-old male with Marfan’s syndrome. His first operation 20 years earlier was performed because of severe aortic insufficiency (AI) and an expanding aortic aneurysm, at which time he underwent SAVR with a mechanical valve (St. Jude Medical, Inc., St. Paul, MN, USA) and a mesh wrap around the ascending aorta.8 Nine years later, he developed prosthetic valve endocarditis and underwent replacement of the valve and root with an aortic homograft. He suffered a perioperative right cerebral infarct resulting in hemiparesis; the patient had subsequent muscle flaps to close a chest defect. After 11 years, he presented with shortness of breath. Echocardiographic left ventricular dimension in diastole was 6.1 cm, with reduced contractility and an ejection fraction of 45%. There was severe aortic valve regurgitation. The aortic arch was dilated. Angiography showed no coronary obstruction. There was severe pulmonary hypertension (79/29 mmHg), with elevated pulmonary capillary wedge pressure (40 mmHg) and an aortic valve area (AVA) of 1.5 cm2. He was deemed inoperable by the heart valve team because of multiple previous cardiac procedures and a previous stroke. It was decided to perform TAVI via a right TF approach. Transesophageal echocardiography (TEE) showed an annulus diameter of 25 mm. Procedural guidance for valve positioning incorporated rotational aortography with 3D reconstruction (Syngo, Dyna-CT Artis Zee, Siemens AG, Forchheim, Germany). Both imaging modalities confirmed severe aortic regurgitation (Fig. 1). A 26-mm valve (Edwards Lifesciences) was advanced around the aortic arch using a
334
OTALVARO, ET AL. TRANSFEMORAL AORTIC VALVE REPLACEMENT
Figure 1. Aortography in patient 1, demonstrating severe aortic insufficiency, and root tortuosity.
Retroflex 3 delivery system over an Amplatz Extra-Stiff guidewire (Cook Medical, Bloomington, IN). The retrograde delivery catheter was fully flexed as the valve traversed the arch; no interference was noted from the homograft-native anastomosis. The valve was positioned in a ‘‘50/50’’ position relative to the insertion points of the homograft valve leaflets, and was deployed without predilation. Immediately following valve implantation, LV pressure was 125/10 mmHg and aortic pressure was 125/65 mmHg; TEE showed the implanted valve functioned well, with trace AI. The aortic regurgitation index (ARI, defined as aortic diastolic blood pressure minus left ventricular enddiastolic pressure, over systolic blood pressure) was 0.45. ARI values above 0.25 have been shown to correlate with improved survival at one year after TAVI.9 He was discharged home three days later, and after 13 months of follow-up is doing well with a New York Heart Association (NYHA) functional class I. Patient 2 is a 50-year-old male with chronic hypertension and end-stage renal disease (ESRD). He underwent aortic root homograft replacement six years earlier for the treatment of dialysis catheter–associated aortic valve endocarditis with severe AI. He developed
Figure 2. Homograft calcification in patient 2.
J CARD SURG 2014;29:333–336
medically refractory heart failure and had several episodes of syncope. TTE confirmed severe homograft aortic valve stenosis, with maximum Doppler velocity across the valve of 428 cm/sec, mean pressure gradient of 41.3 mmHg, and AVA 0.7 cm2, with moderate aortic regurgitation, mild mitral regurgitation with a possible ruptured cord in the posterior valve apparatus and LV systolic function of 20%. Subsequent imaging studies including TEE during the procedure and follow-up TTE failed to show any mitral valve apparatus abnormalities. Angiography showed no coronary stenosis. There was severe calcification of the entire homograft complex, annulus, valve, and aortic root (Fig. 2). After evaluation by the heart valve team, he was determined not to be a candidate for reoperation, and emergency TAVI was thought to be his only option. Gated cardiac computed tomography (CT) confirmed severe aortic homograft calcification; based on the annulus dimension measured by CT, a 29-mm valve was thought to be needed (Fig. 3). Emergency use of this investigational device was granted due to his rapidly deteriorating condition. A right TF TAVI was performed guided by Dyna-CT 3D reconstruction. Balloon aortic valvuloplasty was done with a 25-mm Z-Med balloon (B/Braun Interventional System, Bethlehem, PA, USA); a 29-mm SAPIEN XT (Edwards Lifesciences) valve was advanced retrograde over an Amplatz Extra-Stiff guidewire (Cook Medical). The Novaflex plus delivery catheter was fully flexed around the arch, and the system did not encounter obstruction navigating the aorta. Expansion of the valve frame was somewhat restricted by the calcified homograft valve complex. The mean gradient across the aortic valve decreased from 42 to 7 mmHg, and aortography and TEE demonstrated trace AI. The ARI after TAVI was 0.41. He was discharged 48 hours later. Twenty days post-TAVI, he was asymptomatic with NYHA functional class I. DISCUSSION Our experience shows that treatment of a degenerated aortic valve homograft with the transfemoral
J CARD SURG 2014;29:333–336
Figure 3. CT scan measurements of the calcified aortic homograft annulus in patient 2.
delivery of a balloon-expandable Edwards SAPIEN1 or SAPIEN XT Transcatheter Heart Valve (Edwards Lifescience) valve is feasible. The incidence of redo surgeries for bioprosthetic valves is 25% to 45% with an operative mortality reported 2% to 7% for elective surgeries and 30% for nonelective cases.10 Bioprosthetic valve dysfunction is dependent on the age of the valve; structural degeneration can lead to valvular insufficiency, stenosis, or both.10 Homograft failure is common, with one series reporting insufficiency in 60%, stenosis in 17%, and endocarditis in 15.1%.11–14 The mortality for redo operation for failing homografts is similar to that for other bioprosthetic valves, in the range of 3% to 8%.15,16 Mechanisms of valve failure may be accelerated by ESRD and hemodialysis.17 The long-term durability of TAVI devices will become apparent in the future; current evidence is encouraging. The majority of the cases of the valve-in-homograft technique were done using the Core Valve bioprosthesis,6,18,19 a self-expanding device with very different mechanical properties than the balloon-expandable devices we used. There are only three cases described of valve-in-homograft implantation with a balloon-expandable device, all from either transapical (TA) or median sternotomy with a surgical transaortic approach.20 Our results suggest that the earlier recommendation to avoid TF TAVI should be reevaluated. TAVI can remain an option in patients who are inoperable. To our knowledge, these represent the first reported successful cases using the balloon-expandable Edwards devices from a TF approach. Nonetheless, potential technical issues and concerns remain in regard to TAVI treatment for degenerated aortic homografts. Sizing determination of the valve annulus dimensions is of paramount value. Moreover it is important to note whether the initial surgical homograft procedure necessitated a full root replacement or used a subcoronary implantation. The angulation and distortion of the aortic root, with respect to the rest of the native aorta may be problematic. A full root replacement or an inclusion cylinder technique may maintain the sinotubular and commissural geometry of the aortic homograft and lead to less AI.21 How this influences TAVI remains to be seen, and whether it would differentially
OTALVARO, ET AL. TRANSFEMORAL AORTIC VALVE REPLACEMENT
335
affect the balloon-expandable versus self-expanding bioprosthesis also remains to be determined. For sizing the annulus, we involved a preprocedural transthoracic followed by intraprocedural TEE measuring the diameter from the basal insertion point of one cusp to the other cusp in a longitudinal access view in midsystole.22,23 In our second case, we were guided mostly by CT angiography to delineate the anatomy of the aortic root, its angulation, its relation to the coronary ostia, and the presence of bypass grafts.24,25 A 3D reconstructed rotational aortogram was also helpful for valve positioning guidance. The implementation of multidetector CT measurement of annulus size has reduced the incidence of severe paravalvular leak by avoiding underestimation of annulus area size.9,25,26 While reoperation is indicated in many cases, TAVI may be another alternative for the treatment of degenerated aortic homografts. Acknowledgments: The authors want to thank Dr. Claudia Martinez, Dr. Mauricio G. Cohen, Dr. Rosario Colombo, for their valuable comments and intellectual assistance in writing this manuscript, also to Dr. Eduard Ghersin for providing technical support in 3D CT reconstruction images.
REFERENCES 1. Lardizabal JA, O’Neill BP, Desai HV, et al: The transaortic approach for transcatheter aortic valve replacement: Initial clinical experience in the United States. J Am Coll Cardiol 2013;61:2341–2345. 2. Webb JG, Wood DA, Ye J, et al: Transcatheter valve-invalve implantation for failed bioprosthetic heart valves. Circulation 2010;121:1848–1857. 3. Gotzmann M, Mugge A, Bojara W: Transcatheter aortic valve implantation for treatment of patients with degenerated aortic bioprostheses–valve-in-valve technique. Catheter Cardiovasc Interv 2010;76:1000–1006. 4. Khawaja MZ, Haworth P, Ghuran A, et al: Transcatheter aortic valve implantation for stenosed and regurgitant aortic valve bioprostheses CoreValve for failed bioprosthetic aortic valve replacements. J Am Coll Cardiol 2010; 55:97–101. 5. Chevtchik O, Steger C, Bonaros N, et al: Alternative valvein-root concepts for redo procedures. J Heart Valve Dis 2011;20:593–595. 6. Olsen LK, Engstrom T, Sondergaard L: Transcatheter valve-in-valve implantation due to severe aortic regurgitation in a degenerated aortic homograft. J Invasive Cardiol 2009;21:E197–E200. 7. Sadowski J, Kapelak B, Bartus K, et al: Reoperation after fresh homograft replacement: 23 Years’ experience with 655 patients. Eur J Cardiothorac Surg 2003;23:996–1000, discussion 1000–1001. 8. Robicsek F, Thubrikar MJ: Conservative operation in the management of annular dilatation and ascending aortic aneurysm. Ann Thorac Surg 1994;57:1672–1674. 9. Sinning JM, Vasa-Nicotera M, Chin D, et al: Evaluation and management of paravalvular aortic regurgitation after transcatheter aortic valve replacement. J Am Coll Cardiol 2013;62:11–20. 10. Piazza N, Bleiziffer S, Brockmann G, et al: Transcatheter aortic valve implantation for failing surgical aortic bioprosthetic valve: From concept to clinical application and evaluation (part 2). J Am Coll Cardiol 2011;4:733–742.
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11. Barratt-Boyes BG, Roche AH, Subramanyan R, et al: Longterm follow-up of patients with the antibiotic-sterilized aortic homograft valve inserted freehand in the aortic position. Circulation 1987;75:768–777. 12. O’Brien MF, Harrocks S, Stafford EG, et al: The homograft aortic valve: A 29-year, 99.3% follow up of 1,022 valve replacements. J Heart Valve Dis 2001;10:334–344, discussion 335. 13. Yacoub M, Rasmi NR, Sundt TM, et al: Fourteen-year experience with homovital homografts for aortic valve replacement. J Thorac Cardiovasc Surg 1995;110:186– 193, discussion 193–184. 14. Hasnat K, Birks EJ, Liddicoat J, et al: Patient outcome and valve performance following a second aortic valve homograft replacement. Circulation 1999;100:II42–II47. 15. Joudinaud TM, Baron F, Raffoul R, et al: Redo aortic root surgery for failure of an aortic homograft is a major technical challenge. Eur J Cardiothorac Surg 2008;33: 989–994. 16. Kumar P, Athanasiou T, Ali A, et al: Re-do aortic valve replacement: Does a previous homograft influence the operative outcome? J Heart Valve Dis 2004;13:904–912, discussion 912–3. 17. London GM, Pannier B, Marchais SJ, et al: Calcification of the aortic valve in the dialyzed patient. J Am Soc Nephrol 2000;11:778–783. 18. Lopez-Otero D, Teles R, Gomez-Hospital JA, et al: Transcatheter aortic valve implantation: Safety and effectiveness of the treatment of degenerated aortic homograft. Rev Esp Cardiol 2012;65:350–355. 19. Pasic M, Buz S, Unbehaun A, et al: Transcatheter aortic valve implantation combined with conventional heart surgery: Hybrid approach for complex cardiac pathologic features. J Thorac Cardiovasc Surg 2012;144:728–731. 20. Dainese L, Fusari M, Trabattoni P, et al: Redo in aortic homograft replacement: Transcatheter aortic valve as a
J CARD SURG 2014;29:333–336
21.
22.
23.
24.
25.
26.
valid alternative to surgical replacement. J Thorac Cardiovasc Surg 2010;139:1656–1657. Knott-Craig CJ, Elkins RC, Stelzer PL, et al: Homograft replacement of the aortic valve and root as a functional unit. Ann Thorac Surg 1994;57:1501–1505, discussion 1505–1506. Oh CC, Click RL, Orszulak TA, et al: Role of intraoperative transesophageal echocardiography in determining aortic annulus diameter in homograft insertion. J Am Soc Echocardiogr 1998;11:638–642. Shanewise JS, Cheung AT, Aronson S, et al: ASE/SCA guidelines for performing a comprehensive intraoperative multiplane transesophageal echocardiography examination: Recommendations of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography. J Am Soc Echocardiogr 1999;12: 884–900. Jilaihawi H, Kashif M, Fontana G, et al: Cross-sectional computed tomographic assessment improves accuracy of aortic annular sizing for transcatheter aortic valve replacement and reduces the incidence of paravalvular aortic regurgitation. J Am Coll Cardiol 2012;59:1275–1286. Willson AB, Webb JG, Labounty TM, et al: 3-Dimensional aortic annular assessment by multidetector computed tomography predicts moderate or severe paravalvular regurgitation after transcatheter aortic valve replacement: A multicenter retrospective analysis. J Am Coll Cardiol 2012;59:1287–1294. Binder RK, Webb JG, Willson AB, et al: The impact of integration of a multidetector computed tomography annulus area sizing algorithm on outcomes of transcatheter aortic valve replacement: A prospective, multicenter, controlled trial. J Am Coll Cardiol 2013;62:431– 438.
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Transfemoral Aortic Valve Replacement in Failing Aortic Root Homografts Lynda Otalvaro, M.D.,* Carlos E. Alfonso, M.D.,* William W. O’Neill, M.D.,y Brian P. O’Neill, M.D.,* and Alan W. Heldman, M.D.* *Department of Medicine, Cardiovascular Division and the Elaine and Sydney Sussman Cardiac Catheterization Laboratory, Miami, Florida; and yHenry Ford Hospital, Detroit, Michigan ABSTRACT Transcatheter aortic valve implantation (TAVI) for failing aortic root and valve homografts has been described primarily via a transapical approach. We report the successful treatment of two patients with failing homografts by transfemoral (TF) TAVI. In both cases, TF TAVI was accomplished without technical difficulty and with good clinical outcomes. doi: 10.1111/jocs.12277 (J Card Surg 2014;29:333–336)
Transcatheter aortic valve implantation (TAVI, also known as transcatheter aortic valve replacement) has emerged as a viable option for the treatment of calcific aortic stenosis in patients who are at high risk1 or ineligible for surgical aortic valve replacement (SAVR). Registry studies have also suggested that TAVI may also be a feasible approach to treat degenerated bioprosthetic aortic valves, with a valve-in-valve technique.2–6 Aortic valve and root homografts have been used for surgical treatment of the aortic valve, particularly when there is infective endocarditis. As with any bioprosthetic valve, tissue calcification or degeneration may lead to a need for replacement. Reoperation for homograft failure occurs in 10% to 25% within 15 years, and nearly 50% by 20 years.7 TAVI has been reported for treatment of homograft failure in several cases, and the use of a surgical access approach (via thoracotomy and the left ventricular apex, or sternotomy and direct aortic catheterization) has been advocated based on concerns for disrupting the friable homograft aortic root with the transfemoral method.8 We report our experience of transfemoral (TF) TAVI using the Edwards SAPIEN1 Transcatheter Heart Valve (Edwards Lifesciences, Irvine, CA, USA).
Conflict of interest: Dr. Heldman—research support, Edwards Lifesciences, Inc.; Dr. William O’Neill—research support, Edwards Lifesciences, Inc. Address for correspondence: Alan W. Heldman, M.D., University of Miami Miller School of Medicine, Clinical Research Building, 1120 NW 14th Street, Suite 1127, Miami, FL 33136. Fax: þ1-305-243-1731; e-mail: [email protected]
SURGICAL TECHNIQUE The Institutional Review Board of the University of Miami approved the reporting of these cases Patient 1 is a 52-year-old male with Marfan’s syndrome. His first operation 20 years earlier was performed because of severe aortic insufficiency (AI) and an expanding aortic aneurysm, at which time he underwent SAVR with a mechanical valve (St. Jude Medical, Inc., St. Paul, MN, USA) and a mesh wrap around the ascending aorta.8 Nine years later, he developed prosthetic valve endocarditis and underwent replacement of the valve and root with an aortic homograft. He suffered a perioperative right cerebral infarct resulting in hemiparesis; the patient had subsequent muscle flaps to close a chest defect. After 11 years, he presented with shortness of breath. Echocardiographic left ventricular dimension in diastole was 6.1 cm, with reduced contractility and an ejection fraction of 45%. There was severe aortic valve regurgitation. The aortic arch was dilated. Angiography showed no coronary obstruction. There was severe pulmonary hypertension (79/29 mmHg), with elevated pulmonary capillary wedge pressure (40 mmHg) and an aortic valve area (AVA) of 1.5 cm2. He was deemed inoperable by the heart valve team because of multiple previous cardiac procedures and a previous stroke. It was decided to perform TAVI via a right TF approach. Transesophageal echocardiography (TEE) showed an annulus diameter of 25 mm. Procedural guidance for valve positioning incorporated rotational aortography with 3D reconstruction (Syngo, Dyna-CT Artis Zee, Siemens AG, Forchheim, Germany). Both imaging modalities confirmed severe aortic regurgitation (Fig. 1). A 26-mm valve (Edwards Lifesciences) was advanced around the aortic arch using a
334
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Figure 1. Aortography in patient 1, demonstrating severe aortic insufficiency, and root tortuosity.
Retroflex 3 delivery system over an Amplatz Extra-Stiff guidewire (Cook Medical, Bloomington, IN). The retrograde delivery catheter was fully flexed as the valve traversed the arch; no interference was noted from the homograft-native anastomosis. The valve was positioned in a ‘‘50/50’’ position relative to the insertion points of the homograft valve leaflets, and was deployed without predilation. Immediately following valve implantation, LV pressure was 125/10 mmHg and aortic pressure was 125/65 mmHg; TEE showed the implanted valve functioned well, with trace AI. The aortic regurgitation index (ARI, defined as aortic diastolic blood pressure minus left ventricular enddiastolic pressure, over systolic blood pressure) was 0.45. ARI values above 0.25 have been shown to correlate with improved survival at one year after TAVI.9 He was discharged home three days later, and after 13 months of follow-up is doing well with a New York Heart Association (NYHA) functional class I. Patient 2 is a 50-year-old male with chronic hypertension and end-stage renal disease (ESRD). He underwent aortic root homograft replacement six years earlier for the treatment of dialysis catheter–associated aortic valve endocarditis with severe AI. He developed
Figure 2. Homograft calcification in patient 2.
J CARD SURG 2014;29:333–336
medically refractory heart failure and had several episodes of syncope. TTE confirmed severe homograft aortic valve stenosis, with maximum Doppler velocity across the valve of 428 cm/sec, mean pressure gradient of 41.3 mmHg, and AVA 0.7 cm2, with moderate aortic regurgitation, mild mitral regurgitation with a possible ruptured cord in the posterior valve apparatus and LV systolic function of 20%. Subsequent imaging studies including TEE during the procedure and follow-up TTE failed to show any mitral valve apparatus abnormalities. Angiography showed no coronary stenosis. There was severe calcification of the entire homograft complex, annulus, valve, and aortic root (Fig. 2). After evaluation by the heart valve team, he was determined not to be a candidate for reoperation, and emergency TAVI was thought to be his only option. Gated cardiac computed tomography (CT) confirmed severe aortic homograft calcification; based on the annulus dimension measured by CT, a 29-mm valve was thought to be needed (Fig. 3). Emergency use of this investigational device was granted due to his rapidly deteriorating condition. A right TF TAVI was performed guided by Dyna-CT 3D reconstruction. Balloon aortic valvuloplasty was done with a 25-mm Z-Med balloon (B/Braun Interventional System, Bethlehem, PA, USA); a 29-mm SAPIEN XT (Edwards Lifesciences) valve was advanced retrograde over an Amplatz Extra-Stiff guidewire (Cook Medical). The Novaflex plus delivery catheter was fully flexed around the arch, and the system did not encounter obstruction navigating the aorta. Expansion of the valve frame was somewhat restricted by the calcified homograft valve complex. The mean gradient across the aortic valve decreased from 42 to 7 mmHg, and aortography and TEE demonstrated trace AI. The ARI after TAVI was 0.41. He was discharged 48 hours later. Twenty days post-TAVI, he was asymptomatic with NYHA functional class I. DISCUSSION Our experience shows that treatment of a degenerated aortic valve homograft with the transfemoral
J CARD SURG 2014;29:333–336
Figure 3. CT scan measurements of the calcified aortic homograft annulus in patient 2.
delivery of a balloon-expandable Edwards SAPIEN1 or SAPIEN XT Transcatheter Heart Valve (Edwards Lifescience) valve is feasible. The incidence of redo surgeries for bioprosthetic valves is 25% to 45% with an operative mortality reported 2% to 7% for elective surgeries and 30% for nonelective cases.10 Bioprosthetic valve dysfunction is dependent on the age of the valve; structural degeneration can lead to valvular insufficiency, stenosis, or both.10 Homograft failure is common, with one series reporting insufficiency in 60%, stenosis in 17%, and endocarditis in 15.1%.11–14 The mortality for redo operation for failing homografts is similar to that for other bioprosthetic valves, in the range of 3% to 8%.15,16 Mechanisms of valve failure may be accelerated by ESRD and hemodialysis.17 The long-term durability of TAVI devices will become apparent in the future; current evidence is encouraging. The majority of the cases of the valve-in-homograft technique were done using the Core Valve bioprosthesis,6,18,19 a self-expanding device with very different mechanical properties than the balloon-expandable devices we used. There are only three cases described of valve-in-homograft implantation with a balloon-expandable device, all from either transapical (TA) or median sternotomy with a surgical transaortic approach.20 Our results suggest that the earlier recommendation to avoid TF TAVI should be reevaluated. TAVI can remain an option in patients who are inoperable. To our knowledge, these represent the first reported successful cases using the balloon-expandable Edwards devices from a TF approach. Nonetheless, potential technical issues and concerns remain in regard to TAVI treatment for degenerated aortic homografts. Sizing determination of the valve annulus dimensions is of paramount value. Moreover it is important to note whether the initial surgical homograft procedure necessitated a full root replacement or used a subcoronary implantation. The angulation and distortion of the aortic root, with respect to the rest of the native aorta may be problematic. A full root replacement or an inclusion cylinder technique may maintain the sinotubular and commissural geometry of the aortic homograft and lead to less AI.21 How this influences TAVI remains to be seen, and whether it would differentially
OTALVARO, ET AL. TRANSFEMORAL AORTIC VALVE REPLACEMENT
335
affect the balloon-expandable versus self-expanding bioprosthesis also remains to be determined. For sizing the annulus, we involved a preprocedural transthoracic followed by intraprocedural TEE measuring the diameter from the basal insertion point of one cusp to the other cusp in a longitudinal access view in midsystole.22,23 In our second case, we were guided mostly by CT angiography to delineate the anatomy of the aortic root, its angulation, its relation to the coronary ostia, and the presence of bypass grafts.24,25 A 3D reconstructed rotational aortogram was also helpful for valve positioning guidance. The implementation of multidetector CT measurement of annulus size has reduced the incidence of severe paravalvular leak by avoiding underestimation of annulus area size.9,25,26 While reoperation is indicated in many cases, TAVI may be another alternative for the treatment of degenerated aortic homografts. Acknowledgments: The authors want to thank Dr. Claudia Martinez, Dr. Mauricio G. Cohen, Dr. Rosario Colombo, for their valuable comments and intellectual assistance in writing this manuscript, also to Dr. Eduard Ghersin for providing technical support in 3D CT reconstruction images.
REFERENCES 1. Lardizabal JA, O’Neill BP, Desai HV, et al: The transaortic approach for transcatheter aortic valve replacement: Initial clinical experience in the United States. J Am Coll Cardiol 2013;61:2341–2345. 2. Webb JG, Wood DA, Ye J, et al: Transcatheter valve-invalve implantation for failed bioprosthetic heart valves. Circulation 2010;121:1848–1857. 3. Gotzmann M, Mugge A, Bojara W: Transcatheter aortic valve implantation for treatment of patients with degenerated aortic bioprostheses–valve-in-valve technique. Catheter Cardiovasc Interv 2010;76:1000–1006. 4. Khawaja MZ, Haworth P, Ghuran A, et al: Transcatheter aortic valve implantation for stenosed and regurgitant aortic valve bioprostheses CoreValve for failed bioprosthetic aortic valve replacements. J Am Coll Cardiol 2010; 55:97–101. 5. Chevtchik O, Steger C, Bonaros N, et al: Alternative valvein-root concepts for redo procedures. J Heart Valve Dis 2011;20:593–595. 6. Olsen LK, Engstrom T, Sondergaard L: Transcatheter valve-in-valve implantation due to severe aortic regurgitation in a degenerated aortic homograft. J Invasive Cardiol 2009;21:E197–E200. 7. Sadowski J, Kapelak B, Bartus K, et al: Reoperation after fresh homograft replacement: 23 Years’ experience with 655 patients. Eur J Cardiothorac Surg 2003;23:996–1000, discussion 1000–1001. 8. Robicsek F, Thubrikar MJ: Conservative operation in the management of annular dilatation and ascending aortic aneurysm. Ann Thorac Surg 1994;57:1672–1674. 9. Sinning JM, Vasa-Nicotera M, Chin D, et al: Evaluation and management of paravalvular aortic regurgitation after transcatheter aortic valve replacement. J Am Coll Cardiol 2013;62:11–20. 10. Piazza N, Bleiziffer S, Brockmann G, et al: Transcatheter aortic valve implantation for failing surgical aortic bioprosthetic valve: From concept to clinical application and evaluation (part 2). J Am Coll Cardiol 2011;4:733–742.
336
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11. Barratt-Boyes BG, Roche AH, Subramanyan R, et al: Longterm follow-up of patients with the antibiotic-sterilized aortic homograft valve inserted freehand in the aortic position. Circulation 1987;75:768–777. 12. O’Brien MF, Harrocks S, Stafford EG, et al: The homograft aortic valve: A 29-year, 99.3% follow up of 1,022 valve replacements. J Heart Valve Dis 2001;10:334–344, discussion 335. 13. Yacoub M, Rasmi NR, Sundt TM, et al: Fourteen-year experience with homovital homografts for aortic valve replacement. J Thorac Cardiovasc Surg 1995;110:186– 193, discussion 193–184. 14. Hasnat K, Birks EJ, Liddicoat J, et al: Patient outcome and valve performance following a second aortic valve homograft replacement. Circulation 1999;100:II42–II47. 15. Joudinaud TM, Baron F, Raffoul R, et al: Redo aortic root surgery for failure of an aortic homograft is a major technical challenge. Eur J Cardiothorac Surg 2008;33: 989–994. 16. Kumar P, Athanasiou T, Ali A, et al: Re-do aortic valve replacement: Does a previous homograft influence the operative outcome? J Heart Valve Dis 2004;13:904–912, discussion 912–3. 17. London GM, Pannier B, Marchais SJ, et al: Calcification of the aortic valve in the dialyzed patient. J Am Soc Nephrol 2000;11:778–783. 18. Lopez-Otero D, Teles R, Gomez-Hospital JA, et al: Transcatheter aortic valve implantation: Safety and effectiveness of the treatment of degenerated aortic homograft. Rev Esp Cardiol 2012;65:350–355. 19. Pasic M, Buz S, Unbehaun A, et al: Transcatheter aortic valve implantation combined with conventional heart surgery: Hybrid approach for complex cardiac pathologic features. J Thorac Cardiovasc Surg 2012;144:728–731. 20. Dainese L, Fusari M, Trabattoni P, et al: Redo in aortic homograft replacement: Transcatheter aortic valve as a
J CARD SURG 2014;29:333–336
21.
22.
23.
24.
25.
26.
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