Thorac Cardiovasc Surg 2020; 68(S 01): S1-S72
DOI: 10.1055/s-0040-1705479
Short Presentations
Sunday, March 1st, 2020
Heart Valve Disease
Georg Thieme Verlag KG Stuttgart · New York

Transfemoral Self-Expanding TAVI to Treat Severe AI after Valve-Sparing David Operation

J. Guzman
1  Lahr, Germany
R. Bauernschmitt
1  Lahr, Germany
J. P. Grunebaum
1  Lahr, Germany
R. Sodian
1  Lahr, Germany
› Author Affiliations
Further Information

Publication History

Publication Date:
13 February 2020 (online)

Objectives: Transcatheter aortic valve replacement has become a routine procedure in elderly patients with calcified aortic stenosis. In patients at high operative risk with pure aortic valve insufficiency, transcatheter options are still limited. Among these patients, failing aortic valve reconstruction years after valve-sparing surgery according to David represent a special subgroup; at the time of reoperation, patients usually present with a technically demanding pathology due to the aneurysmatic aortic disease, thus few reports on these patients are available in the literature.

Methods: We report on a 69-year-old patient, who was admitted with a highly symptomatic grade IV aortic insufficiency 12 years after a David operation. In addition to the valvular problem, the patient had calcified aneurysmal enlargement of the entire aorta, and, technically demanding for any transcatheter procedure, a sharp angle between aortic prosthesis and native aorta and a very low ostium of the left main coronary ostium.

Results: As the patient refused open surgical repair, we chose an oversized self-expanding prosthesis (34 mm Evolut R, Medtronic) for the treatment of the valvular pathology from a femoral approach. The prosthesis could be securely anchored without paravalvular leak in echo- and angiography. Diastolic blood pressure rose from 35 to 70 mm of mercury. Patency of the coronary ostia could be demonstrated by immediate angiography after valve implantation. The patient left the hospital after 1 week in markedly improved conditions.

Conclusion: Patients with aortic insufficiency after David operation offer a challenging pathoanatomical situation for any kind of transcatheter valve implantation. Usually, there is no calcium, and the lack of an aortic sinus may put the coronary arteries at risk. On the other hand, the proximal end of the vascular prosthesis provides a rigid and almost circular ring for anchoring. In the case presented, we used an oversized self-expanding prosthesis, mainly to have the opportunity of resheathing and repositioning in case of problems with the coronary ostium or the anastomosis between vascular prosthesis and aorta. As we ended up with a very satisfying result, we conclude that after thorough evaluation of the pathology, transcatheter treatment of those patients appears feasible and promising.