Transcarotid Transcatheter Aortic Valve Replacement for Severe Aortic Valve Stenosis with Narrow Aortic Root and Shaggy Aorta: A Case Report

Abstract

Objective: Transcarotid access for transcatheter aortic valve replacement (TAVR) is a minimally invasive alternative approach if femoral access becomes unfavorable; however, it remains off-label use in Japan. Case Presentation: An 85-year-old female patient with severe aortic valve stenosis presented to our hospital and was diagnosed with acute heart failure. The Society of Thoracic Surgery score and the European System for Cardiac Operative Risk Evaluation 2 were 9.5% and 11.2%, respectively. Computed tomography revealed a small aortic annulus (annulus axis diameter: 18.5 mm × 22.8 mm, perimeter: 67.5 mm, area: 359 mm 2 ), small aortic roots (Valsalva: noncoronary cusp, 22.7 mm; right coronary cusp, 22.8 mm; left coronary cusp, 24.3 mm; sinotubular junction: 18.5 mm × 22.8 mm), and a shaggy aorta with bilateral subclavian artery stenoses. Optimal medical therapy did not work well; therefore, we performed balloon aortic valvuloplasty (BAV). However, BAV did not improve aortic stenosis and worsened aortic regurgitation. The heart team decided to perform transcarotid TAVR owing to the presence of almost no plaque in the left common carotid artery (CCA), and brain magnetic resonance angiography revealed good communications between the anterior and posterior communicating arteries. On the 10th hospital day, transcarotid TAVR was performed, and Sapien 3 20-mm valve was directly implanted during the 30-min clamp time of the left CCA. The procedure was successful, and the clinical course following TAVR was good. Finally, she was discharged to her home on the 24th hospital day. Conclusion:We experienced a successful transcarotid TAVR case. Transcarotid access is a feasible approach in a case requiring an alternative approach.