Pierre Dahdah1, Giuseppe Bruschi2* and Victor Jebara1
1Department of Thoracic & Cardiovascular Surgery, “Hotel-Dieu de France” Hospital, Beirut, Lebanon
2“De Gasperis” Cardiac Center, ASST Niguarda General Hospital, Italy
Received: 12 August, 2016; Accepted: 27 September, 2016; Published: 28 September, 2016
Giuseppe Bruschi, “De Gasperis” Cardiac Center, ASST Niguarda General Hospital, Piazza dell’Ospedale Maggiore 3, 20162 Milan, Italy, Tel: +39.02.6444.2565; E-mail:
Dahdah P, Bruschi G, Jebara V (2016) Direct Aortic Evolut R Implantation as Valve-In-Valve in a Patient Affected by Leriche Syndrome. J Cardiovasc Med Cardiol 3(1): 038-040. DOI: 10.17352/2455-2976.000030
© 2016 Dahdah P,et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Transcatheter valve implantation; Surgery; Aortic; Aortic valve disease
Transcatheter aortic valve implantation (TAVI) has been designed to treat elderly patients with severe aortic stenosis considered high-risk surgical candidates.
Due to the large device size, even of current generation systems, the trans-femoral approach requires favorable ilio-femoral arterial anatomy; this approach is contraindicated in patients with excessive atherosclerosis, calcifications, or tortuosity of ilio-femoral arteries.
We report the case of a 75-year-old female affected by Leriche syndrome who successfully underwent direct aortic (DAo) transcatheter aortic valve implantation with a Medtronic CoreValve Evolut R (Medtronic Inc., Minneapolis, MN, USA) as valve-in-valve implantation to treat a degenerate aortic bioprosthesis.
Transcatheter aortic valve implantation (TAVI) is an appropriate therapy to treat elderly patients with severe aortic stenosis considered high-risk surgical candidates. The safety and effectiveness of TAVI have been demonstrated in numerous observational clinical studies, national registries and also in controlled randomized trial [1,2].
The less invasive approach should be considered the trans-femoral one, nevertheless a number of patients that are referred for TAVI are not eligible for trans-femoral access due to calcification, vascular narrowing, or tortuosity of ileo-femoral arteries. For them, the transapical, subclavian, or direct aortic approaches may be a suitable alternative. The choice of alternative access should be determined by the heart team based on anatomic characteristics and clinical status of the patient.
We report the case of a 75-year-old female affected by Leriche syndrome who successfully underwent valve-in-surgical valve TAVI, through a direct aortic approach, with a Medtronic CoreValve Evolut R.
The Evolut R maintains the cell geometry of the prior CoreValve prosthesis to optimize frame conformance to the native aortic annulus, the delivery system is designed to have a stable and predictable deployment with the advantage, if necessary, to re-sheath, reposition, and redeploy the valve. Evolut R system used the new, catheter-mounted InLine sheath, which eliminates the need for an external sheath; this sheath has a lower equivalent to the outer diameter of a 14-F sheat .
A 75 year-old female was admitted, on January 2016, for congestive heart failure at our hospital. The patient had undergone in 2011 aortic valve replacement with a biological Carpentier-Edwards Magna 23 mm prosthesis (Edwards Lifesciences, Irvine, CA). She was also affected by severe chronic renal failure (creatinine clearance 30 ml/min), oxygen dependent chronic obstructive pulmonary disease (COPD) and epi-aortic vessels vasculopathy with left subclavian artery occlusion and 70% stenosis of left internal carotid artery. The patient suffered from aorto-iliac occlusive disease with complete occlusion of the aorta distal to the renal arteries. To treat Leriche syndrome in 2014 she underwent axillo-bi-femoral bypass with extra-anatomic technique (Figure 1A), at that time transthoracic echocardiography (TTE) revealed normal left ventricle (LV) function with mean gradient of the aortic bioprosthesis of 15 mmHg. Six month after surgery the patient experienced shortness of breath with NYHA Class III; ambulatory TTE showed an increased gradient through the aortic bioprosthesis with a mean gradient of 50 mmHg. Valve thrombosis was suspected and Coumadin was prescribed. Her condition continued to deteriorate in spite of an INR between 2.5 and 3.0. During this period, she was readmitted three times for bouts of congestive heart failure. All blood essays for systemic inflammatory diseases were negative.
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