Endovascular repair of severe aortic coarctation,transcatheter aortic valve replacement for severe aortic stenosis,and percutaneous coronary intervention in an elderly patient with long term follow-up

To the best of our knowledge, there have not been any reports of total transcatheter approach including stenting of severe coarctation of the aorta (CoA), transcatheter aortic valve replacement (TAVR) for concomitant severe aortic valve stenosis, and percutaneous coronary intervention (PCI) to treat significant coronary artery disease in a single patient. We report a 70-year-old female, who presented with uncontrolled hypertension and acute decompensated heart failure (ADHF) and was found to have severe CoA, severe bicuspid aortic valve (BAV) stenosis, and significant proximal left anterior descending (LAD) coronary artery disease. In a multidisciplinary heart team meeting, we decided to perform an endovascular repair of both cardiac and vascular pathologies using a two-stage approach due to the significant comorbidities; mainly uncontrolled hypertension, type 2 diabetes mellitus, chronic obstructive pulmonary disease, and severe calcifications of the ascending aorta. The procedures were successfully performed and the patient was asymptomatic 30?months later at follow-up and was without any significant gradients across the coarctation or the aortic valve.     

In‐hospital and long‐term outcomes of percutaneous balloon aortic valvuloplasty with concomitant percutaneous coronary intervention in patients with severe aortic stenosis

Background

Severe aortic stenosis (AS) often coexists with significant coronary artery disease.

Objective

To evaluate procedural complications and long‐term outcomes of patients with severe AS undergoing balloon aortic valvuloplasty (BAV) and percutaneous coronary intervention (PCI).

Methods

A total of 97 patients with severe AS underwent 104 BAVs as palliative procedure, bridge to definitive treatment, or before urgent non‐cardiac surgery. Patients were followed‐up for at least 12 months.

Results

Of the 97 patients, 34 (35.0%) underwent standalone BAV, 45 (46.4%) underwent BAV with coronary angiography, and 18 (18.6%) BAV with PCI. There were no differences in baseline characteristics and indications for BAV among the groups (P > 0.05). No higher risk of complications after BAV performed with concomitant coronary angiography/PCI was observed. Transcatheter aortic valve implantation was performed after BAV in 13 (13.4%) patients and surgical aortic valve replacement in three (3.1%) patients. In spite of no difference in in‐hospital mortality (5.6% vs. 8.9%; P = 0.76), patients with BAV and concomitant PCI had lower long‐term mortality than patients with BAV and concomitant coronary angiography (28.5% vs. 51.0%; P = 0.03). In multivariable Cox analysis adjusted for age, sex, and body mass index, the Society of Thoracic Surgeons Predicted Risk of Mortality score was identified as the only independent predictor of long‐term mortality for all patients (HR: 1.09, 95%CI: 1.04‐1.15, P = 0.0006).

Conclusions

Concomitant PCI or coronary angiography performed with BAV may not increase the risk of major and vascular complications. Patients with BAV and concomitant PCI may have better survival than patients with BAV and concomitant coronary angiography.     

Impella support following emergency percutaneous balloon aortic valvuloplasty in patients with severe aortic valve stenosis and cardiogenic shock

BackgroundTo investigate the feasibility and outcomes of Impella 2.5 support in patients with severe aortic valve stenosis (AS) and cardiogenic shock (CS), who underwent emergency percutaneous balloon aortic valvuloplasty (BAV) with or without percutaneous coronary intervention (PCI).Methods and resultsWe retrospectively analyzed a consecutive series of patients with severe AS and CS who underwent Impella 2.5 support following emergency BAV with or without subsequent PCI. Outcome data included 30-day outcomes, periprocedural as well as throughout the circulatory support period complications. Eight patients with severe AS and CS were identified. Impella 2.5 implantation was successful following emergency BAV in all patients attempted. Additional PCI was performed in four patients. No periprocedural deaths or periprocedural neurologic events occurred. Mean procedure time was 125.9 min (range 64–210 min). Mortality at 30 days was 50%.ConclusionsImpella 2.5 can be used as hemodynamic support in patients with severe AS and CS following emergency percutaneous BAV and may help to improve tolerability of PCI in these high-risk patients.     

Stenting of the unprotected left main coronary artery in patients with severe aortic stenosis prior to percutaneous valve interventions

AimsHigh-risk patients with severe aortic stenosis (AS) who are candidates for transcatheter valve implantation (TAVI) or balloon aortic valvuloplasty (BAV) may additionally require revascularization of the unprotected left main coronary artery (UPLM). We aimed to assess the feasibility and procedural safety of UPLM stenting in such patients.Methods and ResultsTen cases of UPLM stenting prior to BAV or TAVI at three medical centers over a 2-year period were identified. Mean age was 84±4 years, aortic valve area was 0.70±0.12 cm², left ventricular ejection fraction was 58%±3%, and logistic EuroScore was 32±17. Intraaortic balloon counterpulsation was used in three patients. A single stent was used in seven patients, and two stents were used in three patients. One patient received a bare-metal stent, and the others received drug-eluting stents. No procedural complications occurred, and the patients were hemodynamically stable. Three patients subsequently underwent BAV, and seven underwent TAVI. During 6 months of follow-up, two patients died: one due to AS restenosis 6 months after BAV and one due to vascular complications 18 days after TAVI (34 days after UPLM stenting).ConclusionsStenting of the UPLM in patients with severe AS prior to percutaneous valve intervention seems feasible and safe. This approach may enable more patients to achieve comprehensive percutaneous therapy for severe coronary and valvular disease.     

Comparison of outcomes in high-risk patients>70 years of age with aortic valvuloplasty and percutaneous coronary intervention versus aortic valvuloplasty alone

The goal of this study was to compare outcomes of combined balloon aortic valvuloplasty (BAV) plus percutaneous coronary intervention (PCI) with BAV alone in a surgically high risk, older (>70 years) population with both aortic stenosis (AS) and coronary artery disease (CAD). The medical records, coronary angiograms, and procedural reports of 100 consecutive patients who underwent BAV and coronary angiography at our institution from July 2003 to November 2006 were reviewed. Seventeen patients (mean age 86.2+/-6.4 years) underwent combined (nonstaged) BAV and PCI with a calculated Society of Thoracic Surgery risk score of 13.5%+/-6.7; 13 of these underwent coronary stenting before BAV and 4 after BAV. All 17 patients were successfully treated with this combined strategy. The incidence of periprocedural mortality, myocardial infarction, and stroke was zero. An additional 25 patients (mean age 85.9+/-6.9) with CAD were identified who underwent BAV alone with a Society of Thoracic Surgery risk score of 12.6+/-5.7%. PCI in these patients was avoided primarily because of greater lesion complexity or a perceived low probability of symptomatic benefit. There was 1 procedural death, no myocardial infarction, and 1 postprocedural stroke in these 25 patients. The procedural duration and hospital length of stay for the combined BAV and PCI group was 98.8+/-17.6 minutes and 4.1+/-2.8 days, respectively, and for the BAV only group was 86.2+/-27.3 minutes and 3.3+/-2.1 days, respectively. In conclusion, with appropriate selection, BAV plus PCI was safely performed in this retrospective series of elderly, high-risk patients with severe AS and CAD.     

Ad-hoc percutaneous coronary intervention and transcatheter aortic valve implantation as a combined transfemoral procedure

Coronary artery disease has been reported in more than 50% of patients with severe aortic stenosis above the age of 70 years. Combined surgical aortic valve replacement (SAVR) and coronary artery bypass grafting (CABG) is associated with a higher operative risk. Concomitant coronary artery disease also increases the procedural risk of transcatheter aortic valve implantation (TAVI), and hence, a combined strategy for treating both entities needs to be carefully considered. Data regarding TAVI and percutaneous coronary intervention (PCI) as a combined percutaneous procedure are scarce. We report the case of an 84-year-old woman who presented with non-ST segment elevation myocardial infarction and impending pulmonary edema who was diagnosed with severe aortic stenosis and two-vessel coronary artery disease. Because of an elevated logistic Euroscore of 25% and her unstable presentation, percutaneous coronary revascularization and TAVI were successfully performed in a combined percutaneous transfemoral procedure. She had a smooth recovery and rehabilitation period with significant improvement in her symptoms and functional capacity. Thirty-day follow-up, including transthoracic echocardiography and cardiac magnetic resonance imaging, showed a well-functioning prosthetic valve and no signs of residual myocardial ischemia. We therefore conclude that combined PCI and TAVI is feasible and can be associated with good clinical outcomes in selected cases. Further data and experience are needed to evaluate this strategy.     

Percutaneous balloon valvuloplasty and coronary angioplasty for the treatment of calcific aortic stenosis and obstructive coronary artery disease in an elderly patient

An 81-year-old man with severe calcific aortic stenosis and coronary artery disease who refused surgical therapy was treated with sequential percutaneous balloon aortic valvuloplasty (PBAV) and percutaneous transluminal angioplasty. Before percutaneous balloon valvuloplasty, the mean aortic gradient was 76 mmHg, and the aortic valve area was .45 cm2. The aortic valve was dilated using 15-mm and 18-mm balloons. The mean gradient decreased to 40 mmHG, and the aortic valve area increased to .62 cm2. Percutaneous transluminal coronary angioplasty (PTCA) was performed 2 weeks later, and an 85% proximal left circumflex stenosis was successfully dilated to 20%. No complications were noted during either procedure. At 6-month follow-up, the patient had returned to normal activities and was asymptomatic. Thus, combined therapy with PBAV and PTCA is technically feasible in selected elderly patients with calcific aortic stenosis and anatomically suitable coronary artery disease. This nonsurgical therapeutic approach may be useful in the treatment of selected patients who refuse or who are deferred from cardiac surgery.     

Feasibility of complex coronary intervention in combination with percutaneous aortic valve implantation in patients with aortic stenosis using percutaneous left ventricular assist device (TandemHeart®)

Coronary atherosclerosis is a common finding in patients with severe aortic stenosis. Indeed, aortic stenosis is associated with risk factors similar those of coronary atherosclerosis such as older age, hypertension, diabetes, hypercholesterolemia and smoking. In light of the evolution of percutaneous aortic valve implantation (PAVI) and ongoing improvements in techniques of PCI, a combined approach using PCI and PAVI can be proposed for patients with complex coronary artery and aortic valve disease. This report describes the feasibility of the combination of percutaneous coronary intervention and percutaneous aortic valve implantation with peripheral left ventricular assist device (TandemHeart) support in 3 elderly patients with complex coronary altery disease and aortic stenosis considered too high risk for conventional surgical therapy. © 2009 Wiley‐Liss, Inc.     

Outcomes of concomitant percutaneous coronary intervention and balloon aortic valvuloplasty

Background: Coronary artery disease often coexists with severe aortic stenosis. The feasibility and safety of combined balloon aortic valvuloplasty (BAV) and percutaneous coronary intervention (PCI) are unknown. Aim: To compare outcomes and complications of combined BAV and PCI with BAV alone. Methods: The study cohort consisted of 409 patients with severe aortic stenosis undergoing BAV from 1/2007 to 12/2010. Overall, 329 patients underwent BAV alone and 80 underwent concomitant PCI. Clinical and hemodynamic data, as well as acute and intermediate‐term outcomes, were collected. Results: At the operator's discretion PCI was done before BAV in 66 (82.5%) and after in 14 (17.5%). Patients who underwent concomitant procedures had a higher incidence of prior stroke and a lower incidence of atrial fibrillation. Procedure time and fluoroscopic time were significantly greater in the BAV/PCI group, (90.0 ± 36.6 vs. 72.8 ± 39.8, P = 0.002 and 20.5 ± 10.9 vs. 12.9 ± 7.0, P < 0.001). Significantly more radiographic contrast was used in the BAV/PCI group (95.1 ± 45.5 vs. 36.7 ± 38.4 cm³, P < 0.001. Serious adverse events occurred with equal frequency 13.7 and 17.3%, P = 0.44). Transfusion requirement was also similar (21.2% vs. 20.0%, P = 0.81). The frequency of a periprocedural increase in troponin or creatinine was also similar. In the BAV alone group the mortality rate was 48.6% (n = 160) during a mean follow‐up of 191 days, and in the BAV/PCI group the mortality rate was 40% (n = 32) during mean follow‐up of 175.5 day, P = 0.34. Conclusion: Combined BAV and PCI are safe and are associated with similar complications as BAV alone and may offer protection against myocardial ischemia during BAV. © 2011 Wiley Periodicals, Inc.     

Impella-assisted balloon aortic valvuloplasty

The Impella LP 2.5 left ventricular assist device (Abiomed) is safe and effective for assisting high-risk percutaneous interventions. A 77-year-old woman with severe aortic stenosis, severe coronary artery disease, an ejection fraction of 20%, severe peripheral vascular disease, and other comorbidities presented to a private, tertiary referral hospital with shortness of breath that had been worsening over 2 weeks. The patient underwent a successful, Impella-assisted balloon aortic valvuloplasty (BAV) without complications. Impella support may be considered during BAV in high-risk patients with contraindications for a TandemHeart device (CardiacAssist, Inc.).     

Combined percutaneous balloon dilatation of the aortic valve and coronary angioplasty

A 75 year old man with severe angina caused by aortic stenosis and coronary artery disease was considered to be unsuitable for cardiac surgery after the recent removal of a bronchial carcinoma. Combined percutaneous balloon dilatation of the aortic valve and right coronary angioplasty considerably ameliorated the patient's angina.     

Combined percutaneous balloon dilatation of the aortic valve and coronary angioplasty.

A 75 year old man with severe angina caused by aortic stenosis and coronary artery disease was considered to be unsuitable for cardiac surgery after the recent removal of a bronchial carcinoma. Combined percutaneous balloon dilatation of the aortic valve and right coronary angioplasty considerably ameliorated the patient's angina.     

Effectiveness of same day percutaneous coronary intervention followed by minimally invasive aortic valve replacement for aortic stenosis and moderate coronary disease ("hybrid approach")

In 2005, the investigators described a "hybrid" cardiovascular interventional strategy combining percutaneous coronary intervention (PCI) for coronary artery disease (CAD) followed by valve surgery for patients with urgent complex CAD and valve disease to reduce morbidity and mortality. This hybrid approach has been extended prospectively in elderly, high-risk patients with aortic stenosis scheduled for elective minimally invasive aortic valve replacement (MI-AVR) who, on preoperative coronary angiography, were found to have moderate CAD amenable to PCI. In this prospective, observational series, 18 patients (mean age 76 years) underwent elective hybrid MI-AVR with PCI from May 2003 to February 2006. Five patients had undergone previous coronary artery bypass grafting. Patients underwent coronary angiography the day of (n = 12) or evening before (n = 6) MI-AVR, and after identifying moderately severe CAD, all 18 underwent the implantation of drug-eluting stents to the affected coronary arteries, followed by MI-AVR. Although all patients received standard doses of antiplatelet medications, including acetylsalicylic acid (325 mg before PCI and 325 mg/day thereafter) and clopidogrel (300 mg after PCI, 75 mg/day thereafter for 90 days for the Cypher stent), there were no reoperations for bleeding; only 8 of 18 patients required postoperative blood transfusions. One patient died postoperatively from a colonic perforation, and there were no late mortalities after a mean follow-up of 19 months. In conclusion, this hybrid strategy has low morbidity and mortality and may be a new therapeutic option for older, high-risk patients with combined CAD and aortic valve disease.     

Combined percutaneous aortic valvuloplasty and transluminal coronary angioplasty in adult patients with calcific aortic stenosis and coronary artery disease

Of 120 consecutive balloon aortic valvuloplasty procedures for critical aortic stenosis, valvuloplasty was performed in combination with coronary angioplasty in nine patients (average age 76 years). All nine patients were symptomatic with angina and congestive heart failure before combined procedures. Aortic valvuloplasty was performed with 20 to 23 mm balloon catheter advanced retrogradely from the femoral artery and resulted in an improvement in peak aortic valve gradient (60 +/- 19 to 33 +/- 13 mm Hg; p less than or equal to .01) and calculated aortic valve area (0.7 +/- 0.1 to 1.1 +/- 0.3 cm2; p less than or equal to .01). Single-vessel coronary angioplasty was performed via the femoral approach, with 2.0 to 3.5 mm balloon catheters, and resulted in a mean reduction of a critical coronary stenosis in each patient from 91 +/- 4% to 29 +/- 8%. The site of coronary angioplasty was the left anterior descending artery in three patients, the circumflex artery in three patients, the right coronary artery in two patients, and a bypass graft to the right coronary artery in one patient. Combined procedures were performed with a mean arterial time of 108 min. Complications included groin hematomas (n = 2), transient left bundle branch block (n = 1), and transient atrial fibrillation (n = 1). No patient experienced prolonged chest pain, myocardial infarction, major increase in aortic insufficiency, or embolic phenomena. Eight of the nine patients treated with combined procedures noted significant improvement in symptoms of angina and congestive heart failure and were discharged.(ABSTRACT TRUNCATED AT 250 WORDS)     

Valvuloplasty of congenital aortic stenosis

While percutaneous transluminal valvuloplasty has largely replaced open commissurotomy for congenital pulmonary valve stenosis, the experience with valvuloplasty for congenital aortic stenosis is limited. Between August, 1984 and June, 1987, a total of 27 valvuloplasties were carried out in 25 patients with congenital aortic stenosis; nine infants and 16 patients ranging in age from four to 25 years (mean age 13 +/- 6 years). The indication for valvuloplasty was established on the basis of congestive heart failure or severe stenosis in infants and in the presence of a pressure gradient in excess of 60 mm Hg in those older than one year of age. In eight infants, valvuloplasty reduced the transvalvular pressure gradient from 73 +/- 5 to 36 +/- 9 mm Hg (p less than 0.01; Figure 1). In the 16 patients older than one year of age, the pressure gradient was reduced from 93 +/- 25 to 49 +/- 15 mm Hg (p less than 0.01; Figure 2). The size of the balloon chosen was based on two-dimensional echocardiographic measurements of the aortic ring diameter from inner edge to inner edge. In infants, coronary artery dilating catheters and balloon catheters with an inflated diameter of 4.2 to 8 mm were employed; in children, the balloon diameter selected was 1 to 3 mm less than that of the valve ring diameter, in 15 cases a single-balloon catheter and in one a trefoil catheter. After puncture of the femoral artery and retrograde advancement of a guide-wire into the left ventricle, the balloon catheter was positioned via the guide-wire across the aortic valve.(ABSTRACT TRUNCATED AT 250 WORDS)     

Percutaneous aortic valvuloplasty as a bridge to a high-risk percutaneous coronary intervention

We describe a novel approach of using percutaneous aortic valvuloplasty as a bridge to percutaneous coronary intervention in a patient with refractory congestive heart failure, severe aortic stenosis, severe left ventricular dysfunction and severe 3-vessel coronary artery disease who was not a surgical candidate for aortic valve replacement and coronary artery bypass grafting.     

Hemodynamic and clinical results following percutaneous aortic valve valvuloplasty in adults

We analyzed the results and the follow-up in our first 80 patients after percutaneous balloon aortic valvuloplasty (BAV) since November 1986. Mean age was 74 +/- 10 years, 78 patients were in the NYHA functional classes III or IV. Initially we used relatively small balloons (15-18 mm), later balloons of 20 mm and, with increasing frequency, of 23 mm diameter were utilized, providing very strong inflations at the end of the procedure. The average valve area after BAV increased from initially 0.75 +/- 0.18 to 0.87 +/- 0.28 cm2 after July 1987. Using the 23-mm balloon a mean valve area of 1.05 +/- 0.19 cm2 was obtained. The procedure-related mortality was 2.5%, the total early mortality (30 days) was 6.25%. Other non-fatal complications included two cases of severe valve incompetence requiring valve replacement, one dissection in the aortic root, one cerebrovascular accident, and eight cases of arterial damage (surgical repair). Twenty-six patients with initially successful dilation were restudied hemodynamically, 12 of whom had a restenosis (46%) after 5 months; 13 patients had a second dilatation. The clinical improvement was remarkable (at least 1 NYHA functional class) in 79% of the patients. 33% were improved 1 year and 20% 18 months after the first or eventually the second BAV. Eighteen of the discharged patients died in the follow-up period (two after valve replacement); 20 patients had aortic valve replacement due to restenosis. Our results show a correlation of the maximal balloon size to the valve area after BAV. However, even a perfect technique cannot prevent the restenosis that occurs mostly during the first year. Therefore, BAV may be useful and appropriate for selected patients with inoperable aortic stenosis, but it is no alternative to valve replacement.     

Axillary artery approach for balloon valvoplasty in young infants with severe aortic valve stenosis: medium-term results.

OBJECTIVES: To assess the feasibility and results of trans-axillary approach for balloon aortic valvoplasty (BAV) in early infancy. BACKGROUND: Severe aortic valve stenosis (SAVS) is rare but serious condition in infancy, which may be promptly treated either by surgical aortic valvotomy or BAV. BAV is usually performed via the femoral artery route, which is associated with significant vascular complications and long procedure times. METHODS: BAV via the trans-axillary approach was performed on twenty-seven sequential infants with SAVS presenting to a single tertiary referral center over an 11-year period. Maximum inflated balloon size was less than or equal to the aortic valve diameter. RESULTS: Twenty-seven infants aged 1-77 days underwent BAV. Weight at time of procedure was 2.0-4.42 kgs. The median procedure and screening times were 82 and 7.9 minutes, respectively. Mean instantaneous Doppler gradient across the aortic valve reduced from 68 +/- 33 to 37 +/- 14 mmHg ( p < 0.0001). Three infants developed at least moderate aortic regurgitation. Right arm pulse volume was decreased in 12 infants; 5 received an intravenous heparin infusion. Longer-term follow-up demonstrated reduced or absent peripheral pulse in 5 infants. Transection of the axillary artery occurred in one infant requiring emergency microvascular repair. There was one post-procedural and one late death due to non-cardiac causes. CONCLUSIONS: In early infancy balloon aortic valvoplasty via the axillary artery approach for severe aortic stenosis is an acceptable and safe alternative to the femoral arterial approach and results in short procedure and screening times. Longer-term vascular follow-up is required. (c) 2006 Wiley-Liss, Inc.     

Management of significant left main coronary disease before and after trans‐apical transcatheter aortic valve replacement in a patient with severe and complex arterial disease

We report the case of an 81‐year‐old woman with symptomatic severe aortic stenosis, extremely significant peripheral arterial disease, and obstructive coronary artery disease who underwent percutaneous coronary intervention via a transaxillary conduit immediately before a trans‐apical transcatheter aortic valve replacement performed with a transfemoral device. After deployment of the transcatheter heart valve, there was a left main coronary obstruction and the patient required an emergent PCI. This multifaceted case clearly underlines the importance of a well functioning heart team including the interventional cardiologist, the cardiovascular surgeon, and the echocardiographer. © 2013 Wiley Periodicals, Inc.     

Left main coronary artery bifurcation angioplasty and stenting after aortic valve replacement: a case report

A 43-year-old young lady had closed mitral valvotomy (CMV) in 1994 and aortic valve replacement (AVR) in June 2007. Shortly thereafter, she presented with unstable angina in October 2007 with on-going pain and haemodynamic instability. Coronary angiogram showed tight left main bifurcation stenosis in a left dominant system. Having had open heart surgery (AVR) recently, and being on oral anticoagulation, with on-going ischaemia and unstable haemodynamics, percutaneous coronary intervention (PCI) was considered the most suitable option. She underwent successful PCI with two drug-eluting stents (T-stenting) to left main bifurcation through transradial approach and intra-aortic balloon support. Clinically she remained symptom free and coronary angiogram after 5 months and 15 months of follow-up showed patent stents. This case demonstrates the acute effectiveness of PCI for the treatment of critical left main disease following open heart surgery in patients who are not appropriate surgical candidates.