Transcatheter Aortic Valve Implantation Is Feasible And Safe In High-risk Patients Having Sigmoid Septum
Kizuku Yamashita, Tomoyuki Fujita, Satsuki Fukushima, Yusuke Shimahara, Yuta Kume, Yorihiko Matsumoto, Junjiro Kobayashi.
National Cerebral and Cardiovascular Center, Suita city, Osaka, Japan.
OBJECTIVE: Severe aortic stenosis (AS) is frequently associated with sigmoid septum, for which transcatheter aortic valve implantation (TAVI) is reportedly technically challenging and its therapeutic efficacy might be limited due to remaining pressure gradient in the left ventricular outflow tract (LVOT) post-TAVI. In contrast, we have performed TAVI for this pathology by pin-point deployment of the prosthesis in the annuls. We herein aimed to review clinical outcome of the case series of TAVI for AS with LVOT stenosis.
METHODS: Among a consecutive series of 200 patients having TAVI in our institute in the last 5 years, 91 patients (46%), who were preoperatively diagnosed as having a structural LVOT stenosis with a pressure gradient by computed tomography and echocardiography studies, were reviewed as the study cohort. The Society of Thoracic Surgeons Predicted Risk of Mortality of the cohort was 7.3±3.2%. Echocardiographically, peak jet velocity across the aortic valve was 4.4±0.6 m/s, while peak flow velocity across the LVOT was 1.1±0.4 m/s.
RESULTS: TAVI was successfully performed in all cases without in-hospital mortality, severe morbidities, or moderate degree of paravalvular leak postoperatively, via transfemoral in 55 patients (60%), transapical in 21 patients (23%) or transaortic approaches in 15 patients (16%) by using balloon-expandable device in 64 patients (70%) or self-expandable device in 27 patients (30%). Postoperative echocardiographically, the peak velocity across the aortic valve was 2.0±0.4 m/s with mean gradient being 9.2±3.7 mmHg. Three patients who preoperatively had ≥ 2m/s peak velocity in the LVOT showed a decrease of the peak velocity in the LVOT (1.4±0.3 m/s) at one week post-TAVI. During the complete follow-up of 584±400 days postoperatively, 8 patients died by sudden death, pulmonary disease, cancer and cerebral hemorrhage causes producing a cumulative overall survival of 94% at 1 year and that of 85% at 3 years.
CONCLUSIONS: The sigmoid septum did not preclude feasibility, safety or efficacy of TAVI for severe AS. Further study would be of interest in structural and/or functional change or its mechanism of the sigmoid septum after the release of the valvular stenosis.
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