Case report
Implantation of the CoreValve Percutaneous Aortic Valve

https://doi.org/10.1016/j.athoracsur.2006.05.121Get rights and content

Surgical aortic valve replacement is the only recommended treatment for significant aortic valve stenosis. Percutaneous aortic valve replacement appears to be a novel option for high-risk patients. We report the implantation of the ReValving system (CoreValve, Paris, France) in a 64-year-old woman who was refused aortic valve replacement surgery for critical aortic stenosis and left ventricular dysfunction because of severe pulmonary fibrosis. After anesthesia, the patient was put on femorofemoral cardiopulmonary bypass, and underwent a balloon valvuloplasty with subsequent retrograde aortic valve replacement by the ReValving system. Transesophageal echocardiographic monitoring of the patient’s hemodynamics showed immediate improvements of the valvular area and left ventricular ejection fraction and only traces of paravalvular leaks. The patient was easily weaned from ventilation and resumed activity soon after the surgery. A multidisciplinary approach is presently necessary to offer a reliable and safe procedure.

Section snippets

The Valve

The CoreValve Aortic Valve Prosthesis is a self-expanding heart valve frame designed for the replacement of the native or already-in-place bioprosthetic aortic heart valve. The prosthesis consists of a frame and a biologic valve [3]. The CoreValve consists of a three-part self-expanding frame made from laser cut nitinol tubing (Fig 1). The upper part (aortic level) of the frame increases the prosthesis fixation to the aorta wall and axes the system parallel to the blood flow. The middle part

Anesthesiology Considerations

To allow transesophageal echocardiographic monitoring, the most prudent anesthetic technique is to induce anesthesia in an awake patient with topical anesthesia, with continuous control of systemic arterial pressure. This allows anesthesia induction in a smoother fashion and prevents the acute effect of anesthesia induction and positive pressure ventilation. Regional brain oxygenation was monitored throughout the procedure using the INVOS 4100 (Somanetics Corporation, Troy, MI).

Surgical and Interventional Considerations

The left and right femoral arteries and left femoral vein were exposed for prosthesis insertion and CPB. Beforehand, a 4F pigtail for contrast injection was positioned in the ascending aorta through the right radial artery. When the activated clotting time exceeded 480, CPB was initiated and reached an output of 2.4 L/m2. A 23-mm balloon (Numed, Hopkinton, New York) was advanced through the aortic valve and valvuloplasty was performed. The 23-mm ReValving system was introduced and the valve

Follow-Up

The patient was extubated 3 hours after the procedure and was kept under close surveillance in the intensive care unit for 5 days. Platelet consumption was monitored. After a nadir of 78,000 on day 3, the platelet count returned to within normal limits by discharge on day 9. The rest of the hospitalization was uneventful. Transthoracic echocardiograms on days 7, 30, and 90 confirmed the aortic valve area and the improved LVEF. By 3 months, her clinical status was improved but dependent of her

Comment

The CoreValve ReValving System has been used previously in more than 26 patients outside North America [5] after preliminary experimental data (more than 35 animal procedures) [3]. The indications for its use include severe symptomatic aortic stenosis in patients deemed unsuitable for open procedures by two cardiac surgeons. As the present prosthesis attains a final diameter of 23 mm, its use is restricted to annuli diameter between 19 mm and 24 mm. Patients with important thoracic or abdominal

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Copyright © 2007 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.