Transaxillary Transcatheter Aortic Valve Replacement in a Patient With Previous Aortic Valve-Sparing Root Replacement: A Case Report

• DOI: 10.1016/j.cjco.2022.12.005
• Publication Date: 2022-12-22T17:41:34Z
• Authors: Ryaan EL-Andari; Sabin J. Bozso; Jimmy J.H. Kang; Abdullah Baghaffar; Joel Berube; Michael C. Moon; Benjamin D. Tyrrell; Anoop Mathew; Robert C. Welsh; Jeevan Nagendran
• Keywords: Valve replacement

Novel Teaching Points•Several options are available for alternative access TAVR.•Transaxillary TAVR with a previous David procedure has not been described.•In patients aortic root surgery, is safe option.•Consideration of graft size and type required proper sizing.•Coronary height must be considered valve selection placement. •Several Transcatheter replacement (TAVR) suitable to surgical in specific patient populations. The transfemoral approach the one most commonly used TAVR, although several alternatives possible when contraindicated. infrequently valve-sparing replacements, use alternate these rarely described, given increased procedural complexity. We describe case 75-year-old undergoing transaxillary TAVR. This report demonstrates that effective even surgery. demonstrated recently classified as class Ia indication severe, symptomatic stenosis (AS) aged between 65 80 years.1Otto C.M. Nishimura R.A. Bonow R.O. et al.2020 ACC/AHA guideline management valvular heart disease: American College Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.J Am Coll Cardiol. 2021; 77: e25Crossref PubMed Scopus (623) Google Scholar utilized (TF) approach. However, cases which TF contraindicated—as it up 20% patients, owing peripheral arterial disease or small iliofemoral arteries. These include transapical, transaortic, transcarotid, transcaval, transsubclavian, approaches.2Overtchouk P. Modine T. Alternate TAVI: Stay clear chest.Interven 2018; 13: 145-150Crossref (40) Scholar, 3Bapat V. Tang G.H.L. Axillary/subclavian transcatheter replacement.JACC Cardiovasc Interven. 2019; 12: 670-672Crossref (11) 4Dahle T.G. Castro N.J. Stegman B.M. al.Supraclavicular subclavian Sapien replacement—a novel approach.J Cardiothorac Surg. 16Crossref (8) 5Damluji A.A. Murman M. Byun S. al.Alternative older adults: collaborative study from France United States.Catheter Interv. 92: 1182Crossref (22) 6Madigan Atoui R. Non-transfemoral sites replacement.J Thorac Dis. 10: 4505-4515Crossref (26) Although approaches increasingly common, they still account only fraction total number cases. Additionally, description context surgery limited. Herein, we man who was To our knowledge, this first being performed A 22 years prior presented hospital melena underwent urgent endoscopy. complicated by hypoxemia congestive failure. continued experience shortness breath, after stabilization, further investigation subsequently diagnosed severe AS, his symptoms failure were attributed. patient’s pertinent past medical history included atrial fibrillation, hypertension, dyslipidemia, cerebrovascular accident, an upper gastrointestinal bleed, chronic obstructive pulmonary disease. His (David procedure) appendectomy. At time dual antiplatelet therapy aspirin clopidogrel, addition amlodipine, perindopril/indapamide, rosuvastatin, other medications unrelated conditions. Severe AS echocardiography, based area 0.9 cm2, peak gradient 65.9 mm Hg, mean 31.4 Hg. Echocardiography also trivial regurgitation, mild concentric left ventricular hypertrophy normal function, otherwise structure function. Preoperative coronary angiography no significant lesions. Electrocardiography found sinus rhythm supraventricular bigeminy. computed tomography (CT) following: calcified AS; 26-mm prosthetic straight ascending aorta; reimplanted arteries 16.7 mm, right 27.5 above annulus; annulus measuring 32.3 x 27.9 mm; Valsalva 28.5 24.8 extensive iliac artery atherosclerosis external stenoses bilaterally; minimal symmetrical tortuosity; focal ectasia common (Fig. 1, A-G). results precluded anatomy Review preoperative CT identified would accommodate 29-mm valve, but measured 26 mm. prevent oversizing graft, Edwards S3 (Edwards Lifesciences, Irvine, CA) chosen; additional reasons choice at centre, lower paravalvular leak risk, success. Due age opted As contraindicated chosen due its previously safety efficacy. Under conscious sedation, radial accessed 6-F sheath, femoral vein 7-F sheath. axillary direct cutdown. In procedure, incision landmarked using distal third clavicle, where transverse infraclavicular made approximately 2 cm below medial parallel deltopectoral groove. lateral border pectoralis major muscle moved medially; cephalic pushed laterally. Dissection continues until identification minor divided, tissue posterior dissected brachial plexus identified. Depending location plexus, pulled either inferiorly superiorly. case, inferiorly. Care taken during dissection identify avoid injuring lateral, medial, cords plexus. Once exposed, proximal control could gained, purse-string then placed 5-0 prolene suture. With Seldinger technique, short 0.035-inch wire, followed Avanti sheath (Cordis, Miami Lakes, FL), placement exchange length 0.035-J tipped catheter into root. An AL1 (Medtronic, Dublin, Ireland) over 0.035-wire, wire substituted manually preshaped Lunderquist Super-Stiff (Cook Medical, Bloomington, IN) cross stenotic valve. crossed ventricle, removed, extra stiff, double curl ventricle. 14-F positioned across aorta. advanced position visualized 3-nadir view. ensure appropriate alignment native fluoroscopic guidance, pacing 160 beats per minute, deployed 2). Valve confirmed leak. Perclose (Abbott Laboratories, Chicago, IL) sutures deployed, left-sided sheaths situ. Hemostasis achieved, transferred cardiac care unit hemodynamically stable state. Postoperative echocardiography successful regurgitation 8.5mm had bruising around chest arm held night, acute kidney injury, improving following day. discharged postoperative day condition baseline. Follow-up organized family physician team. Three months postoperatively, alive well home, demonstrating approach, among become recent standard certain populations AS. population contraindications approach.2Overtchouk Given relatively high rates comorbidities becoming effective. underdocumented. procedure. Transaxillary requires careful consideration planning. Patency branch vessels evaluated paramount importance, often have some form cutdown artery, division muscle, near understanding complications morbidity. limited literature describing alternate-access higher-risk those may result slow uptake factors before undertaken. First, shape considered. present, limiting implanted safely. reduce restriction size. Coronary great coronaries replacement. heights sufficiently far concern about issue. When low, obstruction attempting commissural CoreValve Evolut Ireland); frame height, such S3; valves larger stent cell sizes; implantation valve; replacement.7Arshi A. Yakubov S.J. Stiver K.L. al.Overcoming Achilles heel: re-access.Ann 2020; 9: 468-477Crossref Identification variety potential imperative increasing prevalence disease, especially Patients particular interest, population. effective, should risk. authors funding sources declare.