Transcatheter Aortic Valve Implantation Despite Challenging Vascular Access

Abstract

T ranscatheter aortic valve implantation (TAVI) has emerged as a mainstream therapeutic option for valve replacement in patients who are at extreme surgical risk.1 Cardiologists and cardiac surgeons now consider TAVI in patients who have been deemed poor candidates for aortic valve replacement because of their substantial comorbidities.2-4 Careful preoperative planning is crucial in selecting the proper strategy, avoiding intraoperative pitfalls in patients with marginal overall reserve, and minimizing surgical intervention for aortic valve stenosis. 5 The TAVI procedure requires expertise in peripheral and coronary interventional techniques, including large-bore intravenous access. 6 Until recently, lower-profile delivery systems for TAVI were not available in the United States.We describe a case of TAVI that was complicated by severe peripheral artery disease. The elderly patient had contraindications to vascular access that initially made him ineligible for TAVI, so we also describe the additional interventions that were necessary to enable TAVI. Case ReportIn May 2012, a 78-year-old man with critical limb ischemia, recurrent angina, prior aortocoronary bypass, severe aortic stenosis, and New York Heart Association functional class IV symptoms of heart failure was referred for possible aortic valve replacement. His estimated Society of Thoracic Surgeons risk score for TAVI was 21%.2 His aortic valve area was 0.6 cm 2 /cm 2 , which resulted in secondary pulmonary hypertension, a systolic pulmonary artery pressure of approximately 70 mmHg, a moderately depressed left ventricular ejection fraction (0.45), and chronic atrial fibrillation. The patient had substantial additional comorbidities, including end-stage renal disease and tissues weakened by previous mediastinal radiation therapy for a lymphoma.Transesophageal echocardiograms revealed a 20-mm annular diameter. This annular size necessitated the use of a 23-mm Edwards Sapien ® valve (Edwards Lifesciences LLC; Irvine, Calif ), delivered through a 22F RetroFlex ® delivery system (Edwards Lifesciences) in accordance with the manufacturer's recommendation. A 7-mm vessel