Possible early recoil phenomenon in a self-expandable transcatheter bioprosthesis compressed by a huge annular calcification

Possible early recoil phenomenon in a self-expandable transcatheter bioprosthesis compressed by a... Cardiovascular flashlight 1 doi:10.1093/eurheartj/ehy111 CARDIOVASCULAR FLASHLIGHT .................................................................................................................................................... Possible early recoil phenomenon in a self-expandable transcatheter bioprosthesis compressed by a huge annular calcification 1 2 3 Toshihiro Kobayashi , Masanori Yamamoto *, and Satoshi Tsujimoto 1 2 Department of Radiology, Nagoya Heart Center, 1-1-14, Sunadabashi, Higashi-ku, Nagoya, 461-0045 Aichi, Japan; Department of Cardiovascular Medicine, Toyohashi Heart Center, 21-1 Gobudori, Ohyama-cho, Toyohashi, 441-8530 Aichi, Japan; and Department of Cardiovascular Medicine, Nagoya Heart Center, 1-1-14, Sunadabashi, Higashi-ku, Nagoya, 461-0045 Aichi, Japan * Corresponding author. Tel: 181 532 37 3377, Fax: 181 532 36 3366, Email: yamamoto@heart-center.or.jp;masa-nori@nms.ac.jp An 81-year-old woman was hospitalized for heart failure (HF) with severe aortic stenosis (AS). She had a history of liver transplantation under immunosuppressive therapy and multiple comorbidities. Our heart team considered her as a candidate for transcatheter aortic valve implantation (TAVI). Pre-screening multidetector computed tomography revealed the presence of a bulky calcification on the aortic root (Panel A). Therefore, a self-expandable transcatheter heart valve [THV; 26-mm CoreValve Evolut-R (Medtronic, USA)] was implanted via the femoral artery after balloon pre-dilatation (Panels B and C). Haemodynamic measurements showed a remarkable decrease in the peak pressure gradient (PG) between the left ventricle and aorta (Panels D and E). However, she was re-hospitalized for HF approximately 1 month after the initial TAVI procedure, which was associated with recurrent severe AS on echocardiography (Panel F). Multidetector computed tomography was performed to examine the THV performance, which revealed no THV thrombosis, but did indicate that the in- ferior portion of the THV was compressed by large, bilateral calcifications (Panel G). Fluoroscopy also identified shallowing of the THV in re- sponse to left ventricular outflow and a significant re-elevation of PG compared with the first procedure (Panels H and I). The distal portion of the self-expandable THV was the strongest available design, moreover, it was expected to expand gradually after TAVI. Nonetheless, it was hypothesized that the possible cause of this observation was the early recoil phenomenon, particularly given the rarity of this case. Even in the current era of refined TAVI procedures, treating patients with heavy calcification on the aortic root is still a challenge. Multidetector computed tomography findings identified the existence of extensive calcification on the aortic valve complex that contin- ued into the left ventricle outflow track (Panel A). An 18 mm diameter balloon aortic valvuloplasty was performed before implantation of the THV (Panel B). A 26 mm CoreValve Evolut-R was implanted within 4 mm inferior to the annulus without any procedural complications (Panel C). Pre-procedural PG reached 100 mmHg between the left ventricle and aorta (Panel D). Post-procedural PG decreased to less than 5mmHg (Panel E). Echocardiography revealed the recurrence of severe AS with elevation of both peak velocity (4.66 m/s) and mean PG (48 mmHg) (Panel F). Multidetector computed tomography showed the existence of crashed THV compressed by large bilateral calcifica- tions (Panel G). Fluoroscopy confirmed shallowing of the distal portion of the THV (Panel H). The calculated PG was more than 40 mmHg based on the haemodynamic assessment (Panel I). V C Published on behalf of the European Society of Cardiology. All rights reserved. The Author(s) 2018. For permissions, please email: journals.permissions@oup.com. Downloaded from https://academic.oup.com/eurheartj/advance-article-abstract/doi/10.1093/eurheartj/ehy111/4937555 by Ed 'DeepDyve' Gillespie user on 08 June 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Heart Journal Oxford University Press

Possible early recoil phenomenon in a self-expandable transcatheter bioprosthesis compressed by a huge annular calcification

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Oxford University Press
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Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2018. For permissions, please email: journals.permissions@oup.com.
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0195-668X
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10.1093/eurheartj/ehy111
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Abstract

Cardiovascular flashlight 1 doi:10.1093/eurheartj/ehy111 CARDIOVASCULAR FLASHLIGHT .................................................................................................................................................... Possible early recoil phenomenon in a self-expandable transcatheter bioprosthesis compressed by a huge annular calcification 1 2 3 Toshihiro Kobayashi , Masanori Yamamoto *, and Satoshi Tsujimoto 1 2 Department of Radiology, Nagoya Heart Center, 1-1-14, Sunadabashi, Higashi-ku, Nagoya, 461-0045 Aichi, Japan; Department of Cardiovascular Medicine, Toyohashi Heart Center, 21-1 Gobudori, Ohyama-cho, Toyohashi, 441-8530 Aichi, Japan; and Department of Cardiovascular Medicine, Nagoya Heart Center, 1-1-14, Sunadabashi, Higashi-ku, Nagoya, 461-0045 Aichi, Japan * Corresponding author. Tel: 181 532 37 3377, Fax: 181 532 36 3366, Email: yamamoto@heart-center.or.jp;masa-nori@nms.ac.jp An 81-year-old woman was hospitalized for heart failure (HF) with severe aortic stenosis (AS). She had a history of liver transplantation under immunosuppressive therapy and multiple comorbidities. Our heart team considered her as a candidate for transcatheter aortic valve implantation (TAVI). Pre-screening multidetector computed tomography revealed the presence of a bulky calcification on the aortic root (Panel A). Therefore, a self-expandable transcatheter heart valve [THV; 26-mm CoreValve Evolut-R (Medtronic, USA)] was implanted via the femoral artery after balloon pre-dilatation (Panels B and C). Haemodynamic measurements showed a remarkable decrease in the peak pressure gradient (PG) between the left ventricle and aorta (Panels D and E). However, she was re-hospitalized for HF approximately 1 month after the initial TAVI procedure, which was associated with recurrent severe AS on echocardiography (Panel F). Multidetector computed tomography was performed to examine the THV performance, which revealed no THV thrombosis, but did indicate that the in- ferior portion of the THV was compressed by large, bilateral calcifications (Panel G). Fluoroscopy also identified shallowing of the THV in re- sponse to left ventricular outflow and a significant re-elevation of PG compared with the first procedure (Panels H and I). The distal portion of the self-expandable THV was the strongest available design, moreover, it was expected to expand gradually after TAVI. Nonetheless, it was hypothesized that the possible cause of this observation was the early recoil phenomenon, particularly given the rarity of this case. Even in the current era of refined TAVI procedures, treating patients with heavy calcification on the aortic root is still a challenge. Multidetector computed tomography findings identified the existence of extensive calcification on the aortic valve complex that contin- ued into the left ventricle outflow track (Panel A). An 18 mm diameter balloon aortic valvuloplasty was performed before implantation of the THV (Panel B). A 26 mm CoreValve Evolut-R was implanted within 4 mm inferior to the annulus without any procedural complications (Panel C). Pre-procedural PG reached 100 mmHg between the left ventricle and aorta (Panel D). Post-procedural PG decreased to less than 5mmHg (Panel E). Echocardiography revealed the recurrence of severe AS with elevation of both peak velocity (4.66 m/s) and mean PG (48 mmHg) (Panel F). Multidetector computed tomography showed the existence of crashed THV compressed by large bilateral calcifica- tions (Panel G). Fluoroscopy confirmed shallowing of the distal portion of the THV (Panel H). The calculated PG was more than 40 mmHg based on the haemodynamic assessment (Panel I). V C Published on behalf of the European Society of Cardiology. All rights reserved. The Author(s) 2018. For permissions, please email: journals.permissions@oup.com. Downloaded from https://academic.oup.com/eurheartj/advance-article-abstract/doi/10.1093/eurheartj/ehy111/4937555 by Ed 'DeepDyve' Gillespie user on 08 June 2018

Journal

European Heart JournalOxford University Press

Published: Mar 14, 2018

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