International Society For Minimally Invasive Cardiothoracic Surgery

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Oversizing Amplatzer Device For Aortic Valve Closure In Patient With L-VAD, Aortic Regurgitation And Dilated Aortic Annulus
Francesca Nicolo', Andrea Montalto, Marina Comisso, Antonio Lio, Francesco Musumeci.
Azienda Ospedaliera San Camillo, Rome, Italy.

Background. Development of aortic regurgitation (AR) is a significant complication in patients with long-term LVAD support, leading to recurrent clinical heart failure symptoms and significantly increased mortality. Recently, percutaneous interventions, such as transcatheter aortic valve replacement (TAVR) and percutaneous occluder devices, have emerged. TAVR is a challenging procedure in these patients, because of the subsequent difficulty in anchoring the prosthesis in a non-calcified aortic annulus, expecially in the presence of a dilated aortic annulus. Pre-stenting strategy with uncovered stent to prepare an easy landing-zone for TAVR has been described; anyway it's not always feasible in very dilated aortic annulus. We report the case of a percutaneous transcatether aortic valve closure with oversizing of the prosthesis, in order to treat AR in a dilated aortic annulus. Methods: A 68-year old man was admitted to our Hospital with rapidly progressive symptoms of fatigue and shortness of breath 3 years after continuous-flow L-VAD implantation. Severe AR and severe pulmonary hypertension were detected at echocardiography, while a CT-scan showed a virtual basal ring perimeter of 9.3 cm. Because of high surgical risk and contraindication to heart valve transplantation for severe comorbidities, the patient underwent right transfemoral positioning of an Amplatzer PFO MF 30 mm Device (St Jude Medical, Saint Paul, MN, US). At the end of the procedure, a severe paravalvular leak was observed. Therefore, in order to prevent device migration and hemolysis, it was recaptured and removed and, finally, an oversizing Amplatzer MF 35 mm was implanted. Results. Cardiac hemodynamic improved with RPM reduction from 11.400 to 10.600, post-procedural wedge of 6 mmHg, reduction in Pulsatility Index (PI) from 6 to 3 and MAP of 70 mmHg. Absence of paravalvular leaks was detected at TE-echocardiography. Conclusions. We consider this technique a useful novel approach to treat AR in patients with aortic annulus dilatation and L-VAD, that are poor candidates for repeat operation. Further data are needed to assess long-term results.

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