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Successful subclavian transcatheter aortic valve replacement in a nonagenarian patient: Case report and review of literature.

ABSTRACT:

Rationale

In super-aged patients with severe symptomatic aortic stenosis, transcatheter aortic valve replacement (TAVR) is a good treatment option, and the number of TAVR-eligible elderly patients is expected to grow exponentially. We present the case of a nonagenarian woman with severe aortic stenosis who underwent successful subclavian TAVR.

Patient concerns

A 90-year-old Korean woman was brought to our department with dyspnea. On physical examination, a grade IV systolic murmur was auscultated in both the upper sternal borders and the left lower sternal border.

Diagnosis

A transthoracic echocardiogram showed heavy calcification of the aortic valve with an increase in both peak velocity (4.36 m/s) and mean pressure (44.8 mm Hg), indicating severe symptomatic aortic stenosis.

Interventions

After a heart team conference involving interventional cardiologists, cardiac surgeons, and anesthesiologists, subclavian TAVR was performed. Using the left subclavian artery, we successfully deployed a self-expandable valve prosthesis (CoreValveTM Evolut RTM, Medtronic Inc., Minneapolis, MN).

Outcomes

After TAVR, transthoracic echocardiogram showed a decline in both peak velocity (2.06-2.14 m/s) and mean pressure (7.42-7.95 mm Hg) with an increase in the aortic valve area (1.12 cm2). The patient's dyspnea symptoms improved dramatically.

Lessons

In addition to femoral TAVR, subclavian TAVR may be feasible and safe in super-aged patients.

SUBMITTER: Oh S

PROVIDER: S-EPMC8797506 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BackgroundThe past decade has witnessed an ever-increasing momentum of transcatheter aortic valve replacement (TAVR) and a subsequent paradigm shift in the contemporary management of severe aortic stenosis (AS). We conducted a multi-centric TAVR registry based on Chinese patients (the China Aortic valve tRanscatheter Replacement registrY [CARRY]) to delineate the clinical characteristics and outcomes of Chinese patients who underwent TAVR and compare the results between different valve types in different Chinese regions.MethodsCARRY is an all-comer registry of aortic valve disease patients undergoing TAVR across China and was designed as an observational study that retrospectively included all TAVR patients at each participating site. Seven hospitals in China participated in the CARRY, and 1204 patients from April 2012 to November 2020 were included. Categorical variables were compared using the chi-squared test, and continuous variables were analyzed using a t test or analysis of variance (ANOVA) test. The Kaplan-Meier curve was used to estimate the risk of adverse events during follow-up.ResultsThe mean age of the patients was 73.8 ± 6.5 years and 57.2% were male. The median Society of Thoracic Surgeon-Predicted Risk of Mortality score was 6.0 (3.7-8.9). Regarding the aortic valve, the proportion of bicuspid aortic valve (BAV) was 48.5%. During the hospital stay, the stroke rate was 0.7%, and the incidence of high-degree atrioventricular block indicating permanent pacemaker implantation was 11.0%. The in-hospital all-cause mortality rate was 2.2%. After 1 year, the overall mortality rate was 4.5%. Compared to patients with tricuspid aortic valve (TAV), those with BAV had similar in-hospital complication rates, but a lower incidence of in-hospital mortality (1.4% vs. 3.3%) and 1 year mortality (2.3% vs. 5.8%).ConclusionsTAVR candidates in China were younger, higher proportion of BAV, and had lower rates of post-procedural complications and mortality than other international all-comer registries. Given the use of early generation valves in the majority of the population, patients with BAV had similar rates of complications, but lower mortality than those with TAV. These findings further propel the extension of TAVR in low-risk patients.Trial registrationhttps://www.chictr.org.cn/ (No. ChiCTR2000038526).

Project description:IntroductionTranscatheter aortic valve replacement (TAVR) is a minimally invasive procedure to replace a diseased and faulty aortic valve in patients with severe aortic stenosis. As TAVR gains popularity among lower-risk younger patients with a longer life expectancy; there is a need to investigate the long-term shortcomings and limitations of the procedure for this patient group. One such shortcoming is that commissural alignment of transcatheter heart valves (THV) appears to be random; meaning that the THV neo-commissures can misalign with the native commissures of the aortic valve during deployment or self-expansion.ObjectivesIdentify techniques and procedures used to obtain commissural alignment in TAVR. Evaluate the effectiveness of these procedures in terms of the degree of commissural alignment. Analyse the impact of commissural alignment on coronary filling and re-access.MethodsTwo electronic online databases were searched to identify existing literature relevant to the aim and objectives of this review: EBSCOhost and PubMed. After search filters were applied and duplicates removed; a total of 64 articles from both databases were screened against the inclusion/exclusion criteria. This resulted in a total of thirteen articles which met the objectives of this review and thus; were included.ResultsAll studies focused on a patient centered approach involving pre-TAVR computed tomography to obtain commissural alignment. Other studies modified this approach and combined techniques. All studies that implemented a technique to reduce commissural misalignment were significantly successful in obtaining commissural alignment when compared to a study in which alignment was random when no technique was implemented. Severe coronary overlapping in commissural aligned heart valves was relatively low compared to severe coronary overlapping when no technique was implemented.ConclusionsAn increase in optimal commissural alignment via introduction of an alignment technique may seem attractive; however; the categorization of commissural alignment is arbitrary and does not accurately reflect real life clinical implications. Further research is needed to determine whether a routine procedure to achieve commissural alignment is necessary in low-risk younger patients undergoing TAVR.